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Goals. To describe the purpose of the preoperative assessment To provide strategies to minimize operative risks . The Big Question: Should this patient go for surgery ?. - goal of surgery - urgency of surgery ( elective, urgent, emergent) - patient’s/family’s goals and wishes

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  • To describe the purpose of the preoperative assessment

  • To provide strategies to minimize operative risks

The big question should this patient go for surgery
The Big Question:Should this patient go for surgery?

- goal of surgery

- urgency of surgery (elective, urgent, emergent)

- patient’s/family’s goals and wishes

- baseline function, co-morbidities

- life expectancy

- anticipated outcomes/complications

Preoperative assessment purposes
Preoperative Assessment -Purposes

  • Not just for “clearance”

  • To identify factors associated with increased risks of specific complications related to a procedure

  • To recommend a management plan to minimize these risks

Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric Medicine: An Evidence Based Approach, 4th ed. New York: Springer; 2003.

What do geriatricians worry about
What Do Geriatricians Worry About?

  • Delirium

  • Infection

  • Pressure sores

  • Malnutrition

  • Functional decline

    • increased mortality

    • poorer quality of life

    • need for increased care/change of place of living

Common sense geriatric rules
Common Sense Geriatric “Rules”

  • Organ reserves are diminished

  • Complications are more likely

  • Less is often more

  • Test only what you are able and prepared to correct and what will improve outcome

  • You minimize complications, if you prevent prolonged bed rest (pre- and post-op)

Preoperative assessment components
Preoperative Assessment - Components

  • Functional Assessment

  • Cognitive Assessment

  • Nutritional Assessment

  • Review of advance directives

Functional assessment
Functional Assessment

  • American Society of Anesthesiologists (ASA) score

    • Class I A normal healthy patient for elective operation

    • Class II A patient with mild systemic disease

    • Class III A patient with severe systemic disease that limits activity but is not incapacitating

    • Class IV A patient with incapacitating systemic disease that is a constant threat to life

    • Class V A moribund patient that is not expected to survive 24 hrs with or without the operation

Cognitive assessment
Cognitive Assessment

  • Dementia and Hx of delirium are major predictor of post-op delirium

  • Patients with delirium have higher mortality

  • Know your patient’s baseline cognitive function (Mini-Cog, CAM, etc.)

Nutritional assessment
Nutritional Assessment

  • Poor nutrition is a risk factor for

    • pneumonia

    • poor wound-healing

    • 30-day mortality

  • Hypoalbuminemia (<3.3mg/dL)

    • increased length of stay

    • increased rates of readmission

    • unfavorable disposition

    • increased all-cause mortality

Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA1994;272:1036.

Strategies to minimize risk pre operative
Strategies to Minimize Risk - pre-operative

  • Routine screening is low yield

    • Pre-op testing should be based on the type and urgency of surgery

  • Manage hypertension

    • lower blood pressure to under 180/110

  • Avoid long periods without nutrition

  • Treat easily reversible factors (anemia, infection, etc)

  • Use ß-blockers peri-operatively for major surgery, if not contra-indicated

Strategies to minimize risk post operative
Strategies to Minimize Risk - post operative

  • Control diabetes without causing hypoglycemia

  • Pay attention to constipation/urination

  • Mobilize early/DVT prophylaxis

  • Minimize use of psycho-active medication

  • Control pain (your dementia patient won’t do PRN well)

  • Avoid prolonged periods without nutrition

  • Involve the families


  • Older adults have decreased reserves in multiple organ systems

  • Disease burden and functional capacity outweigh age when assessing preoperative risk

  • Collaboration among providers helps to identify functional, cognitive and nutritional deficits/risks and to create management plans to minimize these deficits/risks when possible