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  1. Peri-operative Care of Gynecological Geriatric Patients R. Keith Huffaker, MD, MBA, FACOG

  2. Disclosures • None

  3. References/Sources • Known concerns • UpToDate (Falcone) • FPMRS review course (Ridgeway) • Obstetrics & Gynecology • My input

  4. Overview • In past 100 years, life expectancy increased approximately 30 years • Women spend 1/3 of lives in postmenopausal state • Persistent slow reduction of physical abilities • Number of women over 65yo • Increase from 32mil to 40 mil from 1990 to 2010 • Will increase to 75mil in 2050 • 75yo can expect to live 12 more years • Functional • Independent • Decisions to operate • Biologic age,not chronologic age • Health status

  5. Loss of • Bone • Muscle • Cardiopulmonary reserve • Sensory acuity • Connective tissue integrity • Renal function • Nerve conduction speed • Etc.

  6. Increasingly susceptible to disease/complications as immune function declines • GI function often slows • H. pylori common • Sensitive to NSAIDs • Insulin resistance increases

  7. General Consequences of Physiologic Decline • Vulnerable to acute stress • More chronic diseases • DM • Cardiac • Pulmonary • Evaluation of organ function • Renal readily done • Others more challenging • Heart • Lung • Cognitive • Bottom line is surgical risk increases

  8. Medicare database of over 66,000 women over 65yo underwent surgery for urinary incontinence • 30 day mortality 0.33% • MI, PE, CVA, DVT, Pneumonia each 1% • Sultana, et al. Am J of ObstetGynecol 1997; 176:344. • Comparison of 120 women over 79yo v. 1497 women 50-79 • Older age: longer mean stay • More UTIs, sepsis, psychiatric events, respiratory problems • No significant differences in death, cardiovascular events, thrombosis or wound infections • Friedman, et al. Am. J of ObstetGynecol 2006; 195:547.

  9. What are the four most common geriatric post-op complications? • A. Falls, delirium, surgery infections, electrolyte imbalances • B. CVA, MI, PE, DVT • C. Pulmonary edema, CHF, DVT, CVA • D. Surgery infections, PE, CVA, DVT

  10. Four Common Geriatric Postop Complications • Answer: A • Falls • 30% of community dwelling >65y each yr • Fractures, morbidity, mortality, cannot get up • Delirium • 17% of gyn-onc surgical pts • Mortality • Longer hospital stays • NH/SNF placement

  11. Surgery infections • Impaired ADLs • Decrease immune function • Electrolyte imbalance • Age • Renal function • Fluid mgt—periop

  12. Preparing for surgery • Is the patient a surgical candidate? • Look at her • Initial assessment • Probe deeper • Other opinions • PCP • Cardiology • Etc. • Manage patient expectations • Be very clear regarding goals of surgery • Vaginal surgery, obliterative procedures • Sexual activity discussion—open and frank

  13. Most and probably all of my surgeries are intended to improve quality of life • Conservative options (pessaries) • Delay surgery until patient is medically optimized

  14. General Pre-operative Evaluation • H & P • Anesthesia pre-op requirements • Labs • Often arbitrary • CBC • BMP • Optimize general medical condition prior to surgery

  15. CXR • Certainly for pts >= 60yo • I use 50yo • Cardiac disease • Lung disease • ECG • May need additional evaluation • Determined by PCP or cardiologist • Smoking cessation 8wk or more before surgery

  16. Communication • Decreased hearing • Slowed mental processing • Include friends/family • Use written or print materials • Plain language—8th grade • Allow questions from patient/family • Confirm patient/family understanding

  17. Informed consent • Limit postoperative misunderstandings • Include family/friends • Ask patient to state her understanding of plan • Risks/potential complications • “Indicated procedures” for unexpected findings • Document discussions

  18. Ambulation Concerns • May need OT or PT involvement • Preop • Postop • Floor nursing affected • May need help with turning • Can affect respiration which can affect choice of anesthesia

  19. Decreased ambulation affects • Skin care • Wound care • Bladder function • Bowel function • Respiratory function • Cardiovascular function

  20. Ambulation Test • Timed get up and go • Get up from chair w/o using arms • Walk ten feet, turn • Walk back and sit down • >12 sec consider referring for additional mobility testing

  21. Major Medical Problems • Heart disease • Cancer • Stroke • Chronic lower respiratory disease • Alzheimer’s/other dementia • Clotting disorders • Diabetes • Renal disease

  22. The leading cause of death for women 65y and older is: • A. CVA • B. Cancer • C. Cardiovascular disease • D. CHF

  23. Cardiovascular Disease • Answer: C • Leading cause of death for women 65yr and older • Decreased arterial compliance • Increased SBP • Left ventricular hypertrophy • Decreased cardiac output and HR response to stress

  24. Cardiovascular Consequences • Prone to hypotension • Sensitive to increased HR, volume depletion • Syncope, etc. • Decreased CO and HR meaning stress response is dampened and CHF more likely • Impaired BP response to standing, volume depletion, possible heart block

  25. Predictors of adverse periop cardiac events • Ischemic heart disease • CHF • CVD • IDDM • Serum Cr > 2.0mg/dL • Age

  26. The second leading cause of death for women 65y and older is: • A. CVA • B. All forms of cancer combined • C. PE • D. Accidents

  27. Cancer • Answer: B • Second leading cause of death • Must have increased awareness as provider—pre/intra/post-op • Vulvar • Ovarian • Endometrial • Vaginal • Bladder • Other • Always review pathology reports and inform patients

  28. The third leading cause of death for women 65y and older is: • A. Accidents • B. Renal failure • C. Respiratory – all causes • D. CVA / Stroke • E. I don’t care; I just want this to end.

  29. Stroke • Answer: sorry, not E; D • Cerebrovascular disease is #3 cause of death • Past history = increased risk (recent case) • Family history • Mgt of HTN (<120/<80) is key • Be aware of anticoagulant/antiplatelet therapies • When in doubt, involve PCP/Cards/Heme • For me, always involve the above

  30. Chronic Lung Disease • At risk for ventilation problems and post-op infections • Must have pre-op anesthesia evaluation • Increased intra-abdominal pressure • Stress on pelvic floor surgery • Wound problems—dehiscence

  31. Dementia • To operate or not? • Relate Alzheimer’s surgical patient of mine • Ambulation issue • Must involve other care-givers, family, social services, etc. • Affects bladder function, bowel function, etc. • Also keep in mind different but similar: Sundowners affect where patients get confused being in different setting • ex. Pt anxious/confused/hostile in recovery room or floor room after surgery. • Treatment is get her back to normal surroundings.

  32. Clotting disorders • Obvious concerns • Post-op DVT +/- PE • Intra-op bleeding on anti-coagulant therapies • Coumadin, lovenox, heparin, aspirin, Plavix, Predaxa, bridging therapies, etc. • Must stop coumadin and bridge with Lovenox or heparin • Stop Plavix 5 days before surgery • Labs: PT, PTT, INR (1.0), plavix test, etc. • I always involve the prescribing doctor and usually hospitalists. • Hematology • Vascular • Internal Medicine • Prescribing doctor • Pre- and intra-op plan • Post-op plan

  33. Diabetes • Typically type 2/non-insulin-dependent in this age group • Increased risk of comorbidities • Heart • Kidney • Neuropathy (also bladder function) • Vision • Wound/healing complications • Need reasonable control before going to surgery

  34. Renal Disease • Creatinine for chronic function evaluation • BUN for more acute function evaluation • Check for patient’s sake • Check for doctor’s sake • If any question of ureteral injury, pre-op labs might prove/suggest diminished pre-op function • Concern over pre-op ureteral function: perform cystoscopy at start of case or in office to check for ureteral efflux

  35. Anemia • My biggest concern is can a patient tolerate blood loss • Is she anemic pre-op? • Can her heart tolerate blood loss? Fluid replacement? Blood products? • Should surgery be delayed to address anemia? • Typically anemia in older patients will not be surgical emergency (for instance, does not need D&C acutely)

  36. Anemia and IVFs • Be careful with volume replacement • Go slow • I prefer lower rates of infusion such as 75 or 100ml if patient is stable and over 65yo. • Be aware of cardiac function/history • Give only small volume if bolus needed • Be aware of whether patient typically takes HCTZ/Lasix/Spironolactone and whether she took it peri-op

  37. Consider ICU for fluid management • Renal disease • Extensive GI manipulation or resection • Chronic respiratory disease • Close monitoring in first 12 hours post-op • Third space mobilization of extracellular fluid begins 48-72 hours post-op • May cause late onset pulmonary edema • Tachypnea • Oxygen saturation drops

  38. Bones and Joints • Osteoporosis/penia • Osteo/rheumatoid arthritis • Hip/spinal fractures • Joint replacements • Positioning concerns • Candy canes • Allen’s/yellofins • Post-op ambulation • PT • OT • Home health and family assistance

  39. Medications • Review all (with herbals) • Unpredictable in older patients • Many drug trials exclude elderly • Multiple medications and interactions • Start low and go slow • Body fat increases relative to skeletal muscle mass leading to changes in drug distribution and absorption • Drug clearance decreases with renal function slowing and possibly hepatic changes

  40. Medications Drug Adverse Consequences Hypoglycemia Bleeding Impaired cogn., heart block Falls Sedation, urinary retention Constip., sed.,confusion, etc. Death, pneumonia • Insulin • Warfarin • Digoxin • Benzodiazepines • Antihistamines-first gen. • Opioids • Antipsychotics

  41. Medications Drug Adverse Consequences Tendon rup.,hypoglyc., arrhythmia, C. diff. Pulm. Tox., hepatotox. Hyperkalemia, hypoglycemia, derm. rxn • Fluoroquinolones • Nitrofurantoin • TMP-SMX (Bactrim)

  42. Medications • Estrogen • Stop at least 1-2 wk before surgery • See anticoagulants • Other blood thinning agents or medications that may promote hypercoagulation (vit E, fish oil, etc.) • HTN Rx • Beta blockers continued pre- and post-op • Allow anesthesiology to manage because affects their intra-op mgt • Follow BPs post-op before restarting all meds except beta-blockers which must be continued • Fluid medications (lasix, etc.) affect fluid mgt/output/retention

  43. Prior Surgeries • Obtain op notes • Imaging • If likely to affect case • Abd v. L/S v. Robotic v. Vaginal • Consider if back-up/consultants available for surgical site