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Peri-operative Care of Gynecological Geriatric Patients R. Keith Huffaker, MD, MBA, FACOG
Disclosures • None
References/Sources • Known concerns • UpToDate (Falcone) • FPMRS review course (Ridgeway) • Obstetrics & Gynecology • My input
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
Loss of • Bone • Muscle • Cardiopulmonary reserve • Sensory acuity • Connective tissue integrity • Renal function • Nerve conduction speed • Etc.
Increasingly susceptible to disease/complications as immune function declines • GI function often slows • H. pylori common • Sensitive to NSAIDs • Insulin resistance increases
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
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.
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
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
Surgery infections • Impaired ADLs • Decrease immune function • Electrolyte imbalance • Age • Renal function • Fluid mgt—periop
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
Most and probably all of my surgeries are intended to improve quality of life • Conservative options (pessaries) • Delay surgery until patient is medically optimized
General Pre-operative Evaluation • H & P • Anesthesia pre-op requirements • Labs • Often arbitrary • CBC • BMP • Optimize general medical condition prior to surgery
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
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
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
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
Decreased ambulation affects • Skin care • Wound care • Bladder function • Bowel function • Respiratory function • Cardiovascular function
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
Major Medical Problems • Heart disease • Cancer • Stroke • Chronic lower respiratory disease • Alzheimer’s/other dementia • Clotting disorders • Diabetes • Renal disease
The leading cause of death for women 65y and older is: • A. CVA • B. Cancer • C. Cardiovascular disease • D. CHF
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
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
Predictors of adverse periop cardiac events • Ischemic heart disease • CHF • CVD • IDDM • Serum Cr > 2.0mg/dL • Age
The second leading cause of death for women 65y and older is: • A. CVA • B. All forms of cancer combined • C. PE • D. Accidents
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
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.
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
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
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.
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
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
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
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)
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
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
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
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
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
Medications Drug Adverse Consequences Tendon rup.,hypoglyc., arrhythmia, C. diff. Pulm. Tox., hepatotox. Hyperkalemia, hypoglycemia, derm. rxn • Fluoroquinolones • Nitrofurantoin • TMP-SMX (Bactrim)
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
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