Perioperative Care in Geriatrics Tomas L. Griebling, MD, FACS, FGSA Department of Urology The Landon Center on Aging
Surgical Care in Older Adults • Conditions which can be treated surgically are common in older adults • Surgery may be a good treatment option for some geriatric patients • Misconception that surgery is too dangerous for older adults • Patients and families • Professionals
Surgical Care in Older Adults • Careful perioperative evaluation and management can help reduce both morbidity and mortality • Increased attention and research related to surgical care in older adults • Cross-disciplinary principles • Interaction between surgical and non-surgical specialties is critical in this process
ACOVE Surgical Indicators • Assessing Care of Vulnerable Elders • Quality indicators designed to examine delivery of care and help improve clinical outcomes • Measures regarding surgical care included in ACOVE-III • Evidence-based design J Am Geriatr Soc 55: s347-s358, 2007
ACOVE Surgical Indicators • Organized by timing of service • Preoperative • Perioperative • Postoperative • Spectrum of care is important • Consider and begin planning all aspects of care preoperatively
Preoperative Care • Capacity to Consent • Discussion of Goals of Care • Pulmonary Evaluation • Cardiovascular Evaluation • Diabetes Evaluation • Delirium Risk Factor Assessment
Capacity to Consent • IF a vulnerable elder is to have inpatient or outpatient elective surgery, THEN there should be documentation of the patient’s capacity to understand the risks and benefits of the proposed procedure before the operative consent form is presented for signature…..
Capacity to Consent ….. BECAUSE failure to document this information may result in a surgical procedure and surgical outcomes that are not consistent with the patient’s goals of care.
Capacity to Consent • Informed consent • Critical to planning and delivery of quality surgical care • Important aspect of clinical communication • Potential target of liability • Ethical obligation • AMA Code of Ethics • Legislation – all 50 states mandate this
Capacity to Consent • Risk factors that impair or prevent adequate informed consent • Older age • Fewer years of formal education • Delirium • Surrogate consent may be necessary • Cognitive assessment rare even in delirious subjects in prior studies (< 4% cases) Am J Med 103: 410-418, 1997
Capacity to Consent • Independent risk factors for failure to obtain informed consent • Delirium (OR 2.7, 95% CI 1.3 – 5.3) • Less invasive procedure (OR 5.0, 95% CI 2.0 – 12.8) • Not without risks • Need to match with goals of therapy • Potential for liability Am J Med 103: 410-418, 1997
Discussion of Goals of Care • IF a vulnerable elder is to have elective major surgery, THEN patient priorities and preferences regarding treatment options, operative risks, anticipated postoperative functional outcome, and advance directive and designated surrogate decision maker should be discussed preoperatively…..
Discussion of Goals of Care ….. BECAUSE preoperative discussions regarding surgical options, including risks and outcomes, life-sustaining preferences, and presence of an advance directive, may improve the correlation between the patient’s wishes and administered care.
Discussion of Goals of Care • Needed information • Complications • Likelihood for survival • Likelihood for functional decline • Providers often misunderstand patient preferences or don’t discuss • Poor documentation about goals complicates this issue J Am Geriatr Soc 48: s44-s51, 2000
Discussion of Goals of Care • Hospitalized Elderly Longitudinal Project • 63% of patients > 80 years old received at least 1 life-sustaining intervention before death despite voicing a desire for less-aggressive care • Written advance directives • Only documented in about 25% cases • 1990 Patient Self-Determination Act J Am Geriatr Soc 50: 930-934, 2002 Arch Intern Med 164: 1501-1506, 2004
Discussion of Goals of Care • Patient’s prediction of functional status • Self-predictions and current level of function often provides the most accurate information about future outcomes • Factors influencing treatment choice • Burden of treatment • Possible outcomes • Likelihood of possible outcomes New Engl J Med 346: 1061-1066, 2002
Discussion of Goals of Care • Low-burden treatments • Likelihood of poor outcome is strongly correlated with decision to decline even low-burden treatments among older adults • Discussions of goals important • Help maintain patient autonomy • Prevent unnecessary treatments
Preoperative Pulmonary Evaluation • IF a vulnerable elder is to have elective major surgery, THEN a pulmonary review of systems (i.e., history of smoking, baseline exercise tolerance, history of chronic obstructive pulmonary disease (COPD), or asthma) and chest auscultation should be performed preoperatively…..
Preoperative Pulmonary Evaluation ….. BECAUSE vulnerable elders may possess risk factors for the development of postoperative pneumonia, and a pulmonary history and examination can aid in identifying the risk of postoperative pneumonia.
Preoperative Pulmonary Evaluation • Prospective cohort > 160,000 elderly VA patients • Independent risk factors for post-op pneumonia • Increased age (> 60 years) • Recent smoking • History of COPD or stroke • Impaired cognitive or functional status • Weight loss Ann Intern Med 135: 847-857, 2001
Preoperative Pulmonary Evaluation • Many risk factors are non-modifiable • Interventions target post-operative risk reduction in high-risk patients • Incentive spirometry • Intermittent positive-pressure breathing • Minimum pre-operative assessment • Examination of airway, lungs, heart • Exercise tolerance testing if indicated Circulation 100: 1464-1480, 1999
Preoperative Cardiovascular Evaluation • IF a vulnerable elder is to have elective major surgery, THEN an assessment of cardiovascular risk should be performed preoperatively, BECAUSE cardiovascular disease causes a significant amount of postoperative morbidity and mortality.
Preoperative Cardiovascular Evaluation • Risk stratification tools • Many different options available • Self-reported exercise tolerance is very important and a major predictor of outcome • Poor exercise tolerance (< 4 blocks walking or < 2 flights stairs) associated with more cardiac, neurologic complications and transfers to ICU or telemetry Arch Intern Med 159: 2185-2192, 1999
Preoperative Cardiovascular Evaluation • Formal cardiac stress testing used selectively based on risk stratification • Exercise tolerance • 1 MET improvement = mortality reduction of 17% in men and 12% in women • Overall tolerance < 5 METs • 2x increase in postoperative death in men • 3x increase in postoperative death in women Circulation 108: 1554-1559, 2003 N Engl J Med 346: 793-801, 2002
Preoperative Diabetes Evaluation • IF a vulnerable elder is to have elective major surgery, THEN the presence or absence of diabetes mellitus should be documented preoperatively; AND • IF a vulnerable elder with diabetes mellitus is to have elective major surgery, THEN the diabetes regimen and adequacy of diabetes control should be documented preoperatively…..
Preoperative Diabetes Evaluation ….. BECAUSE diabetes mellitus affects perioperative cardiovascular risk and is a major risk factor for wound infection.
Preoperative Diabetes Evaluation • Hyperglycemia impairs wound healing • Blood sugar > 250 mg/dL • Impairs leukocyte function • Prevents immunoglobulin from fixing complement correctly • Increases risk of mortality • Associated with increased length of hospital stays Int Anesthesiol Clin 38: 31-67, 2000 Anesthsiol Clin North Am 22: 93-123, 2004
Preoperative Diabetes Evaluation • Duration of diabetes • Long-standing diabetes (< 10 years) • Increases risk of end-organ disease • Increased risk of associated postoperative complications • Stroke • Myocardial infarction • Deterioration in renal function
Preoperative Diabetes Evaluation • Mechanism of diabetes control • Important to know what patient uses • Influences choices on pre- and post-operative managements • Diet • Oral hypoglycemic agents • Insulin • Goal of serum glucose on day of surgery of < 200 mg/dL Consider delaying elective surgery if necessary until glucose control improved • Discussion continued in Post-operative care section
Preoperative Delirium Risk Factor Assessment • IF a vulnerable elder is to have elective major surgery, THEN he or she should be screened for risk factors for the development of postoperative delirium within 8 weeks before surgery, BECAUSE delirium is common in elderly patients, and identification of patients at risk for delirium may allow prevention or earlier diagnosis and treatment of postoperative delirium.
Preoperative Delirium Risk Factor Assessment • Post-operative delirium is common in older adults • Incidence varies widely in literature • However, associated morbidity and mortality can be significant • Studies suggest increased 2-3 fold increase in mortality in those with post-op delirium • Increases length of stay and need for post-discharge care
Preoperative Delirium Risk Factor Assessment • Predictive models identify risk factors • Visual impairment • Severe illness • Cognitive impairment • Poor functional status • Self-reported alcohol abuse • Electrolyte abnormalities • BUN:creatinine ratio ≥ 18 Ann Intern Med 119: 474-481, 1993 JAMA 271: 134-139, 1994
Preoperative Delirium Risk Factor Assessment • Prior episodes of delirium are also highly predictive of future delirium • Prevention is key • Preoperative planning can help reduce the incidence of post-operative delirium • Discussion continued in Post-operative care section
Perioperative Care • Prevention of Surgical Site Infection • Perioperative Beta-blockade • Anticoagulation for Hip Fracture and Replacement
Prevention of Surgical Site Infection • IF a vulnerable elderly has elective major surgery, THEN prophylactic antibiotics should be administered within 1 hour before incision (2 hours for vancomycin or fluoroquinolone) and discontinued within 24 hours after the end of surgery…..
Prevention of Surgical Site Infection ….. BECAUSE studies show a marked reduction in the relative risk of surgical site infections with the appropriate timing and duration of antibiotic prophylaxis.
Prevention of Surgical Site Infection • National Surgical Infection Prevention Project (NSIPP) • Prospective, randomized, double-blind RCT • Elective GI surgery • If no antibiotics = 4x increase in wound infection or systemic sepsis • Infection rates significantly reduced if antibiotics administered within 1 hour of start of surgical case • Multiple studies support this recommendation Surgery 66: 97-103, 1967
Prevention of Surgical Site Infection • Stopping antibiotics after surgery • Prolonged antibiotic use increases the risk of colonization or infection with antibiotic resistant organisms • NSIPP guidelines recommend routine antibiotics be stopped within 24 hours after surgery • Dependent on multiple patient factors • Tailored to the patient’s needs Clin Infect Dis 38: 1706-1715, 2004
Perioperative Beta-blockade • IF a vulnerable elder with coronary artery disease has elective major surgery, THEN preoperative beta blockade should be considered, and if initiated, it should be continued until discharge, BECAUSE perioperative beta blockade appears to decrease the risk of cardiovascular morbidity and mortality.
Perioperative Beta-blockade • Somewhat controversial • Several studies support this • More recent studies raise questions about safety and possible adverse outcomes • Depends on specific population and individual patient characteristics • Suggests therapy should be tailored by cardiovascular risk status
Perioperative Beta-blockade • Underlying cardiovascular risk important • Retrospective study 780,000 patients in 326 hospitals • Outcomes varied by risk status • Low-risk = no benefit or possible harm • Adjusted OR death = 1.36 (95% CI = 1.27 – 1.45) • High-risk = survival benefit • Adjusted OR death = 0.58 – 0.88 (dependent on risk status) N Engl J Med 353: 349-361, 2005
Perioperative Beta-blockade • Meta-analysis of 22 RCTs showed no reduction in total mortality, cardio-vascular mortality, nonfatal MI, nonfatal cardiac arrest (considered separately) • However, the composite risk of all of these events (combined) was reduced during the first 30 days post-op BMJ 331: 313-321, 2005
Perioperative Beta-blockade • Potential complications • Increased risk hypotension (RR = 1.27) • Increased risk of bradycardia (RR = 2.27) • Overall, the American College of Cardiology and American College of Physicians recommend beta-blockade in selected surgical patients (based on the cardiovascular risk status) J Am Coll Cardiol 39: 542-553, 2002
Anticoagulation for Hip Fracture and Replacement • IF a vulnerable elder has sustained a hop fracture, THEN an anticoagulant regimen should be started; and • IF a vulnerable elder is to have a total hip replacement, THEN an anticoagulation regimen should be started preoperatively or on the evening after surgery…..
Anticoagulation for Hip Fracture and Replacement ….. BECAUSE studies suggest that DVT prophylaxis reduces the incidence of DVT and pulmonary embolism (PE) in elderly patients with hip fracture and undergoing total hip replacement.
Anticoagulation for Hip Fracture and Replacement • Prevalence of DVT in elderly hip fracture patients undergoing arthroplasty ranges from 42 – 57% if no given anti-coagulation prophylaxis • Meta-analysis of RCTs showed that subcutaneous heparin administration yielded a 56% reduction in odds of proximal DVT Chest 126(suppl): 338s-400s, 2004 New Engl J Med 318: 1162-1173, 1988
Anticoagulation for Hip Fracture and Replacement • Comparison trials of various forms of anti-coagulation therapy have yielded mixed results • Low-molecular weight heparins • Warfarin • Other agents (enoxaparin, fondaparinux) • Standard heparin • Intermittent pneumatic compression leggings • Graduated compression stockings
Anticoagulation for Hip Fracture and Replacement • If surgical delay occurs, recommend heparin-based therapy • Surgical delay is associated with decreased mobility, bedrest • Pain may also limit mobility and increase DVT risk • American Geriatrics Society (AGS) recommends all elderly patients undergoing major surgery
Anticoagulation Prophylaxis in Other Surgical Cases • American Geriatrics Society (AGS) recommends all elderly patients undergoing major surgery receive some form of DVT prophylaxis • Graduated compression stockings • Intermittent pneumatic compression leggings • Must be operational prior to induction of anesthesia for maximum effect • Low-molecular weight heparins or regular heparin • Oral warfarin is NOT recommended (harder to control and adjust around time of surgery) J Am Geriatr Soc 49: 664-672, 2004
Postoperative Care • Mobilization • Diabetes Control • Screen for Postoperative Delirium • Cognition and Function at Discharge