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Objectives

Objectives. By the end of this lecture, the participant should be able to identify and describe: The purpose of preoperative assessment How age-related physiologic changes influence perioperative care Components of preoperative assessment How to minimize perioperative risks.

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Objectives

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  1. Objectives By the end of this lecture, the participant should be able to identify and describe: • The purpose of preoperative assessment • How age-related physiologic changes influence perioperative care • Components of preoperative assessment • How to minimize perioperative risks

  2. Why do a Preoperative Assessment? • Identify specific patient related factors which may increase risk for complications • Identify procedural risks and how they can impact recovery • To recommend treatment plans to minimize complications during and after the procedure

  3. Key determinants of preoperative risk • Type of surgery (elective, urgent, emergent) • Functional status at baseline • Life expectancy • Co-morbid conditions • Expected outcomes and complications

  4. Physiological changes associated with aging • Diminished organ reserves • Decreased thermoregulation may increase risk of perioperative hypothermia • Cardiac and vascular stiffening may complicate fluid management • Decreased hepatic blood flow and number of functional nephrons may alter metabolism and clearance of several medications • Sarcopenia may prolong functional recovery • Altered sensory perception may increase risk of postoperative delirium

  5. Perioperative complications in the geriatric patient • Cardiac events • Infection • Delirium • Pressure ulcers • Functional decline • Malnutrition • Inadequate pain control • Deep vein thrombosis

  6. Components of preoperative assessment • Detailed review of clinical history and physical examination • Functional/Physical activity assessment • Cognitive evaluation • Nutritional assessment • Social support • Goals of Care • Advance directives

  7. Functional/Physical Activity Assessment Metabolic EquivalentsExamples 1 Watching television Eating, dressing, cooking, using toilet Walking 1-2 blocks at 2-3 miles per hour Light housework 4 Climbing flight of stairs Walking on ground level at 4 mph Running a short distance Doing heavy chores (eg scrubbing floors, lifting furniture) Playing moderately strenuous sports (eg golf, dance, bowling) >10 Playing strenuous sports (eg tennis, basketball) Holt NF Perioperative Cardiac Risk Assessment Am Fam Physician 2012; 85(3):239-246 Fleisher LA, Beckman JA, Borwn KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery J Am Coll Cardiol. 2007; 50 (17)

  8. ASA Scores American Society of Anesthesiologists (ASA) score: Class I: normal healthy patient for elective surgery Class II: patient with mild systemic disease Class III: patient with severe systemic disease that limits activity but is not incapacitating Class IV: patient with incapacitating systemic disease that is constant threat to life Class V: moribund patient who is not expected to survive 24hrs with or without surgery

  9. Cognitive Assessment • Evaluate baseline cognitive function (Mini-cog, MOCA, MMSE, etc.) • Dementia and history of delirium increase the risk of postoperative delirium • Post-operative delirium associated with predisposing risk factors: • Age ≥ 70, cognitive impairment, limited physical function, history of alcohol abuse, abnormal serum sodium, potassium or glucose, and intraoperative blood loss • Confusion Assessment Method (CAM) is a useful screening tool for delirium

  10. Nutritional Assessment Instant Nutritional Assessment • Hypoalbuminemia (<3.5mg/dl) increases risk of: • Systemic sepsis and pneumonia • Superficial and deep wound infection • Poor wound healing • Pulmonary edema and failure to wean from ventilation • All-cause mortality rate • Increased hospital length of stay and readmission rates Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134:36-42. Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994; 272:1036-1042 Gastroenterol Clin North Am. 2007; 36:1-22

  11. Strategies to Minimize Risk: Pre-operatively • Manage hypertension • Peri-operative β-blockers for major surgery, if not contraindicated • Manage diabetes appropriately • Treat reversible factors (anemia, infection, electrolyte imbalance etc.) • Avoid prolonged periods without nutrition • Pre-operative testing, based on clinical predictors and type of surgery

  12. Assessing Cardiac Risk in Non-cardiac Surgery Emergency Surgery? Proceed to Surgery Yes No Are of major risk factors present? Yes Cancel or postpone surgery; correct acute cardiac conditions No Yes Proceed to surgery Is procedure low risk? No Is patient able to do light housework, climb a flight of steps, walk up a hill, or run a short distance? Yes Proceed to surgery No or unknown Assess for clinical risk factors: Hx of ischemic heart disease, prior or compensated heart failure, history of cerbrovascular disease, diabetes mellitus, renal insufficiency 1 or 2 risk factors ≥3 risk factors 0 risk factors Proceed to surgery with perioperative B-blockade; consider stress testing if it will change management High risk surgery Intermediate risk surgery Proceed to surgery Strongly consider stress testing if it will change management; if not, proceed to surgery with perioperative B-blockade • Fleisher LA, Beckman JA, Borwn KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery J Am Coll Cardiol. 2007; 50 (17)

  13. Strategies to Minimize Risk: Postoperatively • Manage hypertension and monitor volume status • Control blood sugars appropriately in your diabetic pts • Adequate analgesia, avoid prn orders for patients with cognitive impairment • Early mobilization/Avoid prolonged bed rest • DVT prophylaxis • Avoid/Remove catheters if possible • Regularly review medications • Address nutritional needs • Communicate with proxy/family

  14. Summary • Elderly patients have decreased reserves in multiple organ systems which increases their risk for several perioperative complications • Preoperative assessment should be individualized, comprehensive, and multidisciplinary • Comprehensive perioperative management minimizes complications in older patients, especially those with chronic medical problems and functional impairments

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