5th Annual GWEP Wound Care Workshop Ramin Motarjemi

1. Pre-Op Clearance
for
Elderly Patients
Ramin Motarjemi, MD, FACP
Associate Professor of Medicine, UCSD
VA San Diego Healthcare

2. TOPICS COVERED
• Overview of Operative Therapy for Older
People
• Preoperative Assessment and Management
• Perioperative Management of Common
Medical Problems

3. SURGERY IS A COMMON TREATMENT
FOR OLDER PATIENTS
• More than 55% of all surgeries are done in patients
≥65 years old
• Advances in care have lowered surgical risks and
shifted the risk-benefit ratio to favor surgery in
increasingly older patients with more complex
conditions
• While surgery per se is safer, older adults experience
a disproportionate majority of postoperative morbidity
and mortality

4. AGE-RELATED CHANGES
INFLUENCE PERIOPERATIVE CARE
• As a result of normal aging, multiple organ systems
may have limited physiologic reserve
Examples:
 Cardiac and vascular stiffening complicate fluid
management
 Decreased thermoregulation  increased risk of
perioperative hypothermia
 Stiffening of thoracic cage and diminished ciliary
function  decreased pulmonary reserve
 Altered body composition, decreased kidney
function, hepatic blood flow, and hepatic enzyme
activity  changes in pharmacokinetics of drugs

5. PREOPERATIVE CARE
SHOULD BE INDIVIDUALIZED
• Not all organ systems age at the same rate, even
within an individual
• Most older people have one or more chronic
conditions that influence perioperative care, either
directly or through the drugs they use
• Thus, older patients require thorough and
individualized preoperative care, and often benefit
from a multidisciplinary approach

6. SURGICAL DECISION-MAKING
• Geriatricians ideally should assist in the process of
deciding on surgery
• Patient’s goals of care should be elicited
• Surgical consultation and procedure should be
pursued only if consistent with patient-oriented goals

7. TYPE OF ANESTHESIA
Regional versus general anesthesia
– may reduce pulmonary complications, particularly in
older patients with COPD
– lower risk for developing postoperative delirium
– had lower in-hospital mortality
– shorter hospital stays

8. PREOPERATIVE ASSESSMENT:
CARDIOVASCULAR SYSTEM
• The risk of cardiac events is directly related to age
• To calculate cardiac risk:
 ASA classification
www.asahq.org/clinical/physicalstatus.htm
 ACC/AHA guideline
www.circ.ahajournals.org/content/116/17/e418.full.pdf+html

9. PREOPERATIVE CARE:
CARDIOVASCULAR SYSTEM (1 of 2)
• History and physical should be performed
• Supplemental cardiac testing only useful in the
following specific circumstances
 Pre-op ECG useful as baseline in patients with heart
disease undergoing non-low-risk surgery
 In patients with dyspnea of uncertain cause,
consider measurement of LV function
 In patients with moderate or worse valvular
stenosis/regurgitation, check pre-op echo if none in
past year

10. • ECG testing is not necessary in asymptomatic patients
undergoing low-risk procedures provide useful
information, mostly as a baseline for comparing
postoperative cardiac complications,
• The utility of detecting and treating asymptomatic heart
failure preoperatively is unknown.

11. CHOOSING WISELY
Recommendations:
• Don’t perform stress cardiac imaging or advanced
noninvasive imaging as a preoperative assessment in
patients scheduled to undergo low-risk non-cardiac
surgery.
• Patients who have no cardiac history and good
functional status do not require preoperative stress
testing before non-cardiac thoracic surgery.
• Avoid echocardiograms for preoperative/perioperative
assessment of patients with no history or symptoms of
heart disease.

12. Emergency surgery?
No
Yes
Any of the following major risk factors present?
unstable angina, myocardial infarction <6 mo ago,
decompensated heart failure, moderate/severe valvular
disease, dyspnea
Proceed to surgery
Is patient able to do heavy housework, perform yard
work, climb a flight of steps, walk up a hill, or run a short
distance?
Is procedure low risk, (eg, cataract, endoscopic, breast,
plastic) or superficial surgery?
Is patient medically appropriate for and willing to undergo testing for cardiac ischemia and
revascularization before surgery? Will further information on cardiac risk impact decision to proceed with
surgery or perioperative care?
Proceed to surgery
Cancel or postpone
surgery; correct acute
cardiac conditions;
reassess valvular function
with echo; address dyspnea
Again discuss potential risks
and benefits of surgery with
surgeon and patient to
decide whether or not to
proceed with surgery
Yes
No
Yes
No
Proceed to surgeryYes
No or unknown
No to either Yes to both
Calculate cardiac risk;
consider/perform cardiac stress
testing (pharmacologic or
exercise) and if abnormal
revascularize (CABG or PCI)

13. REVASCULARIZATION
• Major indications for revascularization in the
perioperative period
 Significant unprotected left main vessel disease
 3-vessel disease
 2-vessel disease with proximal LAD disease
 Survivors of sudden cardiac death with presumed
ischemic ventricular tachycardia

17. High risk for perioperative complications
• Patients with recent MI (60 days) or unstable angina
• decompensated heart failure
• high-grade arrhythmias
• hemodynamically important valvular heart disease
(aortic stenosis in particular)

18. MANAGEMENT OF PATIENTS WITH CORONARY
STENTS
• Cohort studies identify substantially increased risk of
major adverse cardiac event when surgery is
performed soon after a coronary stent is placed
• Optimal timing for elective surgery:
 Not before 1 month after a bare metal stent
 Not before 6 months after a drug-eluting stent

19. • Continuation of antiplatelet medications given to reduce
stent thrombosis must be carefully weighed against, the
risk of significant postoperative bleeding.
• Except for emergent settings in which surgery cannot be
delayed, we recommend that a platelet P2Y12 receptor
blocker and aspirin be continued for at least the
minimum recommended duration for each stent type and
that elective noncardiac surgical procedures requiring
discontinuation of DAPT be deferred.

20. • Elective surgery after DES implantation in patients
undergoing procedures in which P2Y12 inhibitor therapy
will need to be discontinued may be considered after 3
months if the risk of further delay of surgery is greater
than the expected risk of stent thrombosis.

21. BETA-BLOCKERS
• Should not be initiated on the day of surgery!
• Should be continued in patients who have been on beta-
blockers chronically
• It may be reasonable to begin β-blockers preoperatively
in patients with intermediate- (moderate) or high-risk
myocardial ischemia noted on preoperative stress testing
Inpatients with 3 or more RCRI risk factors
*may be started 2-7 days prior to surgery, although few data suggest starting β-
blockers > 30 days prior to surgery is preferred

22. STATINS
• Should be continued in patients who have been on
statins chronically
• It is reasonable to begin statins preoperatively in patients
undergoing vascular surgery.
• Preoperative initiation of statin therapy may be
considered in patients scheduled for elevated-risk
procedures who have clinical indications for initiation of
statin therapy.

23. PREOPERATIVE ASSESSMENT:
RESPIRATORY SYSTEM
Major risk factors for pulmonary complications:
• Patient-related: age, COPD, ASA class II or greater,
heart failure, ADL deficit, low albumin
• Procedure-related: emergency surgery; prolonged
surgery (>3 hours); AAA repair; neurosurgery; or
thoracic, abdominal, head and neck, or vascular
surgery
• General anesthesia is also a risk factor

24. • Before surgery, there is no need for pulmonary function
testing in the absence of respiratory symptoms.
• Don’t obtain preoperative chest radiography in the
absence of clinical suspicion for intrathoracic pathology.
(except for known cardiac or pulmonary disease in
patients undergoing thoracic, upper abdominal, or AAA
surgery).
PREOPERATIVE ASSESSMENT:
RESPIRATORY SYSTEM

25. PREOPERATIVE ASSESSMENT:
KIDNEY FUNCTION
• Renal and glomerular blood flow decrease with age,
and muscle mass declines, so serum creatinine may
appear normal even when kidney function is not.
• Accurate estimation of GFR is important
• Many drugs used perioperatively may require dosage
adjustment if renal function is impaired.

26. PERIOPERATIVE CARE:
TYPE 2 DIABETES MELLITUS
• Oral drugs are usually held the day of surgery, especially
metformin, which increases the risk of metabolic acidosis
during times of stress
• An option for optimizing glucose control:
 Administer an IV glucose-containing solution at a
constant rate while closely monitoring blood glucose
by fingerstick assay, and
 Administer SC insulin as needed to avoid severe
hyperglycemia until the patient can resume eating

27. PERIOPERATIVE CARE:
TYPE 2 DIABETES MELLITUS
• Insulin-using patients with type 2 diabetes:
 Day of surgery: Hold the outpatient dose of insulin
and give “sliding-scale” insulin as needed
 First day of eating by mouth: A general rule is to give
half the outpatient dose of diabetes drugs, with sliding-
scale insulin as needed
 When patient can consume a usual diet: Resume full
doses of diabetes drugs

28. HYPERTENSION
If the initial evaluation indicates mild or moderate
hypertension and no associated metabolic or
cardiovascular abnormalities, no reason exists to delay the
surgery
Antihypertension medications should be continued during
the perioperative period (with the exception of diuretics on
day of surgery)
A diastolic blood pressure of 110 mm Hg or higher requires
control before undergoing the surgery
Do not stop beta-blockers and clonidine because of
potential heart rate and blood pressure rebound

29. PERIOPERATIVE CARE:
PATIENTS USING CORTICOSTEROIDS
Perioperative administration of “stress doses” of steroids is
appropriate for:
 Patients on prednisone >20 mg/day for >1 week
 Patients with known adrenal insufficiency

30. Elective, uncomplicated surgeries:
Continue the outpatient dose of steroids
Minor procedure:
The equivalent of 25 mg/day IV hydrocortisone the day of surgery only
Moderate surgical stress:
The equivalent of 50 to 75 mg/day IV hydrocortisone (eg, IV
hydrocortisone 20 mg every 8 hours) for 1 to 2 days
High surgical stress:
The equivalent of 100 to 150 mg/day IV hydrocortisone (eg, IV
hydrocortisone 50 mg every 8 hours, beginning within 2 hours of
surgery) for 2 to 3 days
FOR SURGERY

31. ANEMIA
Anemia is common in elderly
Lower Hg is associated with worse outcome, but not clear
whether the association is causal
No reason to post-pone surgery if Hg within target and
patient stable hemodynamically

32. Keep Hg at 7-9, likely closer to 8-9 range, especially if
underlying myocardial ischemia
For elderly patients, prudent transfusion practices to
maintain hemoglobin thresholds of 9–10 g/dL are indicated
No real evidence to support keeping Hg over 10
ANEMIA

33. ANTICOAGULANTS
• An increasing number of the elderly population are taking
Anticoagulants
• Pre-op decision to stop or continue has to be
individualized based on indication, type of surgery and risk
of bleeding

34. CESSATION OF ANTICOAGULATION BEFORE
SURGERY IN OLDER ADULTS
• If not indicated, STOP!
• Weigh protective benefit versus bleeding risk in
patients already on anticoagulation
• Should limit the period without anticoagulation to the
shortest possible interval.
• For other procedures, cessation of warfarin, with or
without low-molecular-weight heparin bridge therapy,
is based on patient’s risk of thromboembolism

35. • 2 factors important; Thromboembolic risk and bleeding
risk
• Do not withhold for cutaneous surgery, dental
extractions, minor oral procedures, or cataract surgery
CESSATION OF ANTICOAGULATION BEFORE
SURGERY IN OLDER ADULTS

36. • It is reasonable to continue anticoagulation throughout
the perioperative period for low bleeding risk procedures.
• For intermediate- and high-risk procedures, the timing of
anticoagulant discontinuation and need for “bridging”
therapy depends on the risk of thrombosis while off
anticoagulants vs. procedural bleeding risk.

37. Most common indications for anticoagulation are:
1) Atrial fibrillation
2) Prosthetic heart valve
3) Recent thromboembolism/VTE

38. High risk
Coronary artery bypass surgery, kidney biopsy, and any
procedure lasting >45 minutes.
Low risk
Low bleeding risk procedures include dental extractions,
minor skin surgery, cholecystectomy, carpal tunnel repair,
and abdominal hysterectomy.

39. ATRIAL FIBRILLATION
• Can stop anticoagulation for surgery generally
• CHA2DS2-VASc Score
• Perioperative thromboembolic risk was 1.2 percent

40. RECENT VTE
• The perioperative risk of VTE is greatest in individuals
with an event within the prior three months
• With a history of VTE associated with a high-risk
inherited thrombophilia.
• Patients who require surgery within the first three months
following an episode of VTE are likely to benefit from
delaying elective surgery, even if the delay is only for a
few weeks.

41. WARFARIN
Stop five days before elective surgery (ie, the last dose of
warfarin is given on day minus 6) check the PT/INR on the
day before surgery if possible. Goal is INR 1.4-1.5

42. Copyrights apply

43. BRIDGING INDICATION
Embolic stroke or systemic embolic event within the previous
three months
Mechanical mitral valve, Mechanical aortic valve and additional
stroke risk
Atrial fibrillation and very high risk of stroke (eg, CHADS2 score
of 5 or 6, stroke or systemic embolism within the previous 12
weeks, concomitant rheumatic valvular heart disease with mitral
stenosis)
Venous thromboembolism (VTE) within the previous three
months (preoperative and postoperative bridging)
Previous thromboembolism during interruption of chronic
anticoagulation

44. TEMPORARY IVC FILTER
• Placement of a temporary IVC filter indicated in patients
with a recent (within the prior three to four weeks) acute
VTE who require interruption of anticoagulation for a
surgery or major procedure in which it is anticipated that
therapeutic-dose anticoagulation will need to be delayed
for more than 12 hours postoperatively.

45. PARKINSON DISEASE
Require special attention during the perioperative
period, since:
Withholding medications in patients who are NPO
can cause significant worsening of symptoms
Have side effects of medications, all of which may
worsen with the addition of surgery and anesthesia.
Can hold medication on day of Surgery

46. DEMENTIA
A known history of cognitive impairment or dementia puts
the patient at high risk for post-op delirium
Careful documentation of the patient's preoperative
cognitive status is strongly recommended
Ensure that the patient has an advance directive and a
designated healthcare proxy or surrogate decision makers.

47. PREOPERATIVE ASSESSMENT:
RISK OF DELIRIUM
• Preoperative risk factors in noncardiac surgery:
 Age ≥ 70 years
 Cognitive impairment
 Limited physical function
 History of alcohol abuse
 Abnormal serum sodium, potassium, or glucose
 Intrathoracic surgery or abdominal aneurysm surgery

48. SUMMARY
• Preoperative assessment should be individualized,
comprehensive, and, often, multidisciplinary.
• Attentive perioperative management minimizes
complications in older patients, especially those with
chronic medical problems and functional impairments.