Transcript University of Kansas Medical Center

Perioperative Evaluation and
Management with Geriatric
Considerations
Theresa King, M.D
University of Kansas School of
Medicine
Department of Internal MedicineHospitalist
REVIEW:
 General Perioperative Principles
 Cardiac
 Pulmonary
 Endocrine
 Medication Issues
 Geriatric Considerations
PERIOPERATIVE CONSULTATION
 We do not “clear” patients for surgery!
 We determine individual patient risks and
make recommendations to reduce those
risks. “Evaluation and optimization.”
 No surgery or procedure is without riskimpossible to predict outcomes.
PATIENT HISTORY and PHYSICAL









HPI
PMH
PSH
Medications
Allergies
SH, FH
ROS
Physical Exam
Lab, Radiology, etc.
Past Surgical History








“The past predicts the future”.
Problems with anesthesia?
Problems with bleeding? DVT’s/PE’s?
Intra-operative CVA or MI?
ICU?
On Ventilator?
Associated organ failure?
Sepsis?
Review of Systems
 Specific questions should include:
 Dyspnea? Wheezing? Cough?
 Anginal symptoms?
 Ankle or generalized swelling?
 Abnormal bleeding?
SOCIAL HISTORY- TOBACCO
 Recent large meta-analysis: no suggestion, either from any
single study or from combinations of studies, that quitting
smoking shortly before surgery (within 8 weeks)increases
postoperative complications.
 Stopping Smoking Shortly Before Surgery and Postoperative Complications: A
Systematic Review and Meta-analysis, Katie Myers, MSc, CPsychol; Peter Hajek, PhD;
Charles Hinds, FRCP, FRCA; Hayden McRobbie, MBChB, PhD ,Arch Intern Med.
2011;171(11):983-989. doi:10.1001/archinternmed.2011.97.
 Encourage cessation at any time before surgery.
SOCIAL HISTORY- ALCOHOL
 Associated nutritional deficiencies
 History of withdrawal issues including DT’s
FAMILY HISTORY
 Specifically, problems with bleeding,
anesthesia and DVT/PE.
 CAD Hx, including age of onset
CARDIAC ASSESSMENT
 Multiple risk stratification tools exist.
 In assessment documentation, cite which
guidelines were used.
2009 ACCF/AHA Focused Update on Perioperative Beta
Blockade Incorporated Into the ACC/AHA 2007 Guidelines
on Perioperative Cardiovascular Evaluation and Care for
Noncardiac Surgery (Journal of the American College of
Cardiology, available at
http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.07.010)
ACC/AHA Cardiac evaluation and care algorithm for noncardiac surgery based on active
clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50
years of age or greater
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
STEP 1: URGENCY of SURGERY
 Is it emergent, urgent, semi-urgent or
elective?
STEP 2:
ACC/AHA ACTIVE CARDIAC
CONDITIONS
• Unstable coronary syndromes
• Unstable or severe angina
• Recent MI (within previous 30 days)
• Decompensated heart failure
• Significant arrythmias
• Severe valvular disease
ACC/AHA ACTIVE CARDIAC ISSUES
(cont)
 Active Cardiac Conditions for Which the Patient Should Undergo
Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of
Evidence: B):
 Unstable coronary syndromes, Unstable or severe angina* (CCS class
III or IV), Recent MI (within 30 days)
 Decompensated HF (NYHA functional class IV; worsening or new-onset
HF)
 Significant arrhythmias, High-grade atrioventricular block, Mobitz II
atrioventricular block, Third-degree atrioventricular heart block,
Symptomatic ventricular arrhythmias, Supraventricular arrhythmias
(including atrial fibrillation) with uncontrolled ventricular rate (HR greater
than 100 beats per minute at rest), Symptomatic bradycardia, Newly
recognized ventricular tachycardia
 Severe valvular disease, Severe aortic stenosis (mean pressure
gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or
symptomatic), Symptomatic mitral stenosis (progressive dyspnea on
exertion, exertional presyncope, or HF)
STEP 3:
ACC/AHA PROCEDURE RISK
STRATIFICATION
 Cardiac Risk* Stratification for Noncardiac Surgical
Procedures
 VASCULAR (reported cardiac risk often more than 5%):
Aortic and other major vascular surgery, Peripheral vascular
surgery
 INTERMEDIATE (reported cardiac risk generally 1% to 5%):
Intraperitoneal and intrathoracic surgery, Carotid
endarterectomy, Head and neck surgery, Orthopedic surgery,
Prostate surgery
 LOW (reported cardiac risk generally less than 1%):
Endoscopic procedures, Superficial procedure, Cataract
surgery, Breast surgery, Ambulatory surgery
*Combined incidence of cardiac death and nonfatal myocardial infarction.
STEP 4:
ACC/AHA FUNCTIONAL CAPACITY
 Measured in METS(metabolic energy
equivalents)
 >4 METS MOST DESIRABLE
 4 METS=
 Ability to walk 2 blocks on level ground OR
carry 2 bags of groceries up one flight of
stairs without symptoms
ACC/AHA Estimated Energy Requirements for Various
Activities
Can You…
1 Met Take care of yourself?
4
Mets
Can You…
4
Climb a flight of stairs
Mets or walk up a hill?
Eat, dress, or use the
Walk on level ground
toilet?
at 4 mph (6.4 kph)?
Walk indoors around
Do heavy work around
the house?
the house like
scrubbing floors or
lifting or moving heavy
furniture?
Walk a block or 2 on
Participate in
level ground at 2 to 3
moderate recreational
mph (3.2 to 4.8 kph)?
activities like golf,
bowling, dancing,
doubles tennis, or
throwing a baseball or
football?
Do light work around
> 10 Participate in
the house like dusting Mets strenuous sports like
or washing dishes?
swimming, singles
tennis, football,
From : A Report of the American College
of Cardiologyor skiing?
basketball,
STEP 5:
ACC/AHA CLINICAL RISK FACTORS





Hx of heart disease
Hx of compensated or prior heart failure
Hx of cerebrovascular disease
Diabetes mellitus
Reduced renal function (serum creat >2.0 or
a > 50 % increase above baseline)
ACC/AHA RECOMMENDATIONS for PREOPERATIVE
NONIVASIVE EVALUATION OF LEFT VENTRICULAR
FUNCTION
 Class IIa
 It is reasonable for patients with dyspnea of unknown origin to
undergo preoperative evaluation of left ventricular (LV)
function. (Level of Evidence: C)
 It is reasonable for patients with current or prior heart failure
with worsening dyspnea or other change in clinical status to
undergo preoperative evaluation of LV function if not
performed within 12 months. (Level of Evidence: C)
 Class IIb
 Reassessment of LV function in clinically stable patients with
previously documented cardiomyopathy is not well
established. (Level of Evidence: C)
 Class III
 Routine perioperative evaluation of LV function in patients is
not recommended. (Level of Evidence: B)
ACC/AHA RECOMMENDATIONS for
PREOPERATIVE RESTING 12-LEAD ECG




Class I
 Preoperative resting 12-lead ECG is recommended for patients with at least 1
clinical risk factor* who are undergoing vascular surgical procedures. (Level of
Evidence: B)
 Preoperative resting 12-lead ECG is recommended for patients with known
coronary heart disease, peripheral arterial disease, or cerebrovascular disease
who are undergoing intermediate-risk surgical procedures. (Level of Evidence: C)
Class IIa
 Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk
factors who are under-going vascular surgical procedures. (Level of Evidence: B)
Class IIb
 Preoperative resting 12-lead ECG may be reasonable in patients with at least 1
clinical risk factor who are undergoing intermediate-risk operative procedures.
(Level of Evidence: B)
Class III
 Preoperative and postoperative resting 12-lead ECGs are not indicated in
asymptomatic persons undergoing low-risk surgical procedures. (Level of
Evidence: B)
ACC/AHA RECOMMENDATIONS for NONINVASIVE
STRESS TESTING BEFORE NONCARDIAC SURGERY
 Class I
 Patients with active cardiac conditions in whom
noncardiac surgery is planned should be evaluated
and treated per ACC/AHA guidelines before
noncardiac surgery. (Level of Evidence: B)

Class IIa
 Noninvasive stress testing of patients with 3 or
more clinical risk factors and poor functional
capacity (less than 4 metabolic equivalents [METs])
who require vascular surgery is reasonable if it will
change management. (Level of Evidence: B)
ACC/AHA RECOMMENDATIONS for NON-INVASIVE
STRESS TESTING BEFORE NONCARDIAC SURGERY
(cont)
 Class IIb
 Noninvasive stress testing may be considered for patients with
at least 1 to 2 clinical risk factors and poor functional capacity
(less than 4 METs) who require intermediate-risk noncardiac
surgery if it will change management. (Level of Evidence: B)
 Noninvasive stress testing may be considered for patients with
at least 1 to 2 clinical risk factors and good functional capacity
(greater than or equal to 4 METs) who are undergoing vascular
surgery. (Level of Evidence: B)
 Class III
 Noninvasive testing is not useful for patients with no clinical
risk factors undergoing intermediate-risk noncardiac surgery.
(Level of Evidence: C)
 Noninvasive testing is not useful for patients undergoing lowrisk noncardiac surgery. (Level of Evidence: C)
ACC/AHA THERAPY RECOMMENDATIONS for BBLOCKER USAGE


Class I
 Beta blockers should be continued in patients undergoing surgery who are
receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension,
or other ACC/AHA Class I guideline indications. (Level of Evidence: C)
 Beta blockers should be given to patients undergoing vascular surgery who are
at high cardiac risk owing to the finding of ischemia on preoperative testing.
(Level of Evidence: B)
Class IIa
 Beta blockers are probably recommended for patients undergoing vascular
surgery in whom preoperative assessment identifies coronary heart disease.
(Level of Evidence: B)
 Beta blockers are probably recommended for patients in whom preoperative
assessment for vascular surgery identifies high cardiac risk, as defined by the
presence of more than 1 clinical risk factor.* (Level of Evidence: B)
 Beta blockers are probably recommended for patients in whom preoperative
assessment identifies coronary heart disease or high cardiac risk, as defined by
the presence of more than 1 clinical risk factor,* who are undergoing
intermediate-risk or vascular surgery. (Level of Evidence: B)
ACC/AHA THERAPY RECOMMENDATIONS for BBLOCKER USAGE (cont)
 Class IIb
 The usefulness of beta blockers is uncertain for patients
who are undergoing either intermediate-risk procedures
or vascular surgery, in whom preoperative assessment
identifies a single clinical risk factor.* (Level of Evidence:
C)
 The usefulness of beta blockers is uncertain in patients
undergoing vascular surgery with no clinical risk factors
who are not currently taking beta blockers. (Level of
Evidence: B)
 Class III
 Beta blockers should not be given to patients
undergoing surgery who have absolute contraindications
to beta blockade. (Level of Evidence: C)
ACC/AHA RECOMMENDATIONS for
STATIN THERAPY
 Class I
 For patients currently taking statins and scheduled for
noncardiac surgery, statins should be continued. (Level
of Evidence: B)
 Class IIa
 For patients undergoing vascular surgery with or without
clinical risk factors, statin use is reasonable. (Level of
Evidence: B)
 Class IIb
 For patients with at least 1 clinical risk factor who are
undergoing intermediate-risk procedures, statins may be
considered. (Level of Evidence: C)
Proposed treatment for patients requiring percutaneous coronary
intervention (PCI) who need subsequent surgery
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
Proposed approach to the management of patients with previous percutaneous coronary
intervention (PCI) who require noncardiac surgery
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
ASSESSMENT DOCUMENTATION
EXAMPLE
 “ Per ACC/AHA guidelines, no further cardiac
risk stratification is indicated in this patient
undergoing a semi-urgent, intermediate risk
surgery with no active cardiac conditions who
has a good functional status (METS > 4) and
no clinical risk factors.”
PULMONARY RECOMMENDATIONS
PREOPERATIVE
 Consider using a course of preoperative corticosteroids
for patients with COPD or asthma who are not optimized
 Consider delaying elective surgery if respiratory infection
present
 Consider antibiotics for patients with infected sputum
 Patient education regarding lung expansion maneuvers
INTRAOPERATIVE
 Encourage shorter procedures, when
possible, to minimize duration of anesthesia
 Encourage use of epidural or spinal
anesthesia instead of general, if appropriate
 Encourage use of regional anesthesia in very
high risk patients
POSTOPERATIVE
 Deep breathing exercises or incentive
spirometry
 REMIND PATIENTS THAT BREATHS
MUST BE VERY SLOW AND DEEP TO
BE MAXIMALLY EFFECTIVE!
 Consider using epidural analgesia for pain
instead of IV opioids, if appropriate, to
minimize respiratory depression
ENDOCRINE- DIABETES MELLITUS
 Recommendation for general hospitalized
patients
 Preprandial glucose goal of <140
 Peak postprandial goal of <180
 In ICU patients
 Glucose goal of 140-180
 Referenced from the American Association of Clinical Endocrinologists and
American Diabetes Association Consensus Statement on Inpatient Glycemic
Control. Endocr Pract. 2009;15:1–17
ENDOCRINE- DM (cont.)
 Insulin gtt may be used
 Type I diabetics should never be without basal
insulin
 Hold oral agents until patient eating after surgery
 Reduce last Lantus insulin dose before surgery
by half OR reduce am NPH dose by half
 Hold metformin if likely patient will require IV
contrast administration
ENDOCRINE- ADRENAL
INSUFFICIENCY
 Suppression of the hypothalamic-pituitaryadrenal (HPA) axis should be suspected in
patients:
 on equivalent of 20 mg/d or more of
prednisone for 3 or more weeks
ENDOCRINE- ADRENAL
INSUFFICIENCY (cont)
 For minor procedures or surgery under local
anesthesia, give usual am steroid dose
 For moderate surgical stress (ex,
cholecystectomy, total joint replacement),
give usual am dose. Give 50 mg
hydrocortisone IV just prior to procedure and
25 mg q 8hrs for 24 hrs, then resume usual
home regimen.
ENDOCRINE- ADRENAL
INSUFFICIENCY (cont.)
 For major surgical stress (ex, open heart
surgery), give usual am dose. Give 100 mg
of IV hydrocortisone before induction of
anesthesia, then 50mg q 8hr for 24 hours.
Taper dose by half each day down to
maintenance level.
When in doubt about the appropriate
perioperative management of a
specific medical condition, contact a
sub-specialist for recommendations.
MEDICATIONS
Perioperative medication management is
complex and should be discussed with the
surgeon and anesthesiologist, considering
risk vs. benefit issues.
MISCELLANEOUS





Early ambulation
DVT prophylaxis!!!!!!!
Pain control- concurrent bowel regimen
PPI w steroids
Avoid fluid overload and possible associated
respiratory failure
GERIATRIC CONSIDERATIONS








Delirium
Cognitive Dysfunction
Nutrition
Pain
Physical Therapy
Hydration and Volume Status
Medications
Discharge Planning
GERIATRIC STATISTICS
 People aged 65 years and older comprise 13% of the
population but 36% of acute care admissions.
 Almost 25% of patients age 65 years or older are
discharged to another institution.
 Almost 15% of patients admitted from home are
discharged to a nursing home.
Geriatrics Review Syllabus Sixth Edition, Chapter 13 Hospital Care, Chapter 14
Perioperative Care
DELIRIUM
 Defined by fluctuation in awareness, memory, attention,
thinking and consciousness
 Develops in ~30% of hospitalized elderly patients
 Major predictors include presence of dementia at
baseline, age > 70 years, history of ETOH abuse,
dehydration (BUN:creatinine >/= 18:1), severe physical
or sensory impairment, severe illness
DELIRIUM (cont)
 Anticholinergic medications and those with
similar properties (some anti-histamines such as
diphenhydramine)
 Avoid chemical and physical restraints, unless
patient severely agitated or at risk of harming
self or others.
COGNITIVE DYSFUNCTION
 May last weeks to months
 Not always obvious
 Different from “emergence delirium” (immediately follows
surgery and often associated with anesthesia
medications wearing off)
 Common. Three months after surgery > 10% continue to
have it.
 Cause not well understood.
NUTRITION
 Nutritional supplementation can improve
mortality and morbidity (ex., decrease
pressure ulcers)
 Especially target patients who are
undernourished at baseline
PAIN
 Epidural pain control may be preferable, if
appropriate
 PCA (patient-controlled analgesia) use may
lead to better control and decreased opioid
use
PHYSICAL THERAPY
 Early PT following hip fracture surgery in
elderly not shown to lower mortality BUT
improves other outcomes such as fewer days
of pain and less pain as well as better
mobility at 2 months postop.
HYDRATION and VOLUME STATUS
 Dehydration is risk factor for delirium
 Modify IV fluid type and rate based on
individual factors, such as presence of CHF
MEDICATIONS
 Accurate medication reconciliation is vital at
transitions of care.
 Administer pneumococcal and influenza
vaccinations per guidelines.
 Avoid medications from Beers Criteria for
Potentially Inappropriate Medication Use in
Older Adults medication list.
 http://www.americangeriatrics.org/files/docum
ents/beers/2012BeersCriteria_JAGS.pdf
 DISCHARGE PLANNING
STARTS AT THE TIME OF
ADMISSION and is
exceedingly important in the
geriatric population!
SOURCES






2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into
the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care
for Noncardiac Surgery, Journal of the American College of Cardiology, available at
http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.07.010
American Association of Clinical Endocrinologists and American Diabetes Association
Consensus Statement on Inpatient Glycemic Control. Endocr Pract. 2009;15:1–17
Perioperative Evaluation.Yale Office-based Medicine Curriculum, Eighth Edition,
Volume 2, 2013.
Hamrahian AH, Roman SR, Milan S. The surgical patient taking glucocorticoids. In:
UpToDate, Post TW (Ed), UpToDate. (Assesses on March 20, 2014.)
Geriatrics Review Syllabus Sixth Edition, Chapter 13 Hospital Care, Chapter 14
Perioperative Care, Chapter 32 Delirium
Palmer RM. Perioperative Care of the Elderly Patient: An Update. Cleveland Clinic
Journal of Medicine. 2009;76(4):S16-S21