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PREOPERATIVE EVALUATION in the ELDERLY

PREOPERATIVE EVALUATION in the ELDERLY. Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu. PROCESS . A series of modules and questions Step #1: Power point module with voice overlay

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PREOPERATIVE EVALUATION in the ELDERLY

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  1. PREOPERATIVE EVALUATION in the ELDERLY Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu

  2. PROCESS A series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

  3. OBJECTIVES: The Learner will be able to: • List the key tasks in a preoperative evaluation • Identify risk factors for surgical mortality and morbidity in the elderly • Describe pre-op evaluation of health, cognitive, nutritional and functional status

  4. In non emergent, non-cardiac surgery AGE Mortality LOS <59 4% 6 days 60-69 6% 70-79 10% >80 13% 8 days Polancyk CA et al. Ann Intern Med 2001 April 17;134:637-643 Highest risk Emergency surgery Abdominal/thoracic surgery Neurosurgery Radical neck resection King MS Preoperative Evaluation AAFP July 15 2000vol. 62, No 2 Epidemiology

  5. PROCEDURE RISK:Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Am. Coll. of Cardiology/Am. Heart Assoc. Task Force 1996 and executive summary. J. Am. College Cardiology Vol 39, No 3 2002

  6. FUNCTIONS of the EVALUATOR in PREOPERATIVE ASSESSMENT 1) History and physical exam to determine health, cognitive, nutritional and functional status 2) Risk assessment and advise patient and surgeon 3) Preoperative testing 4) Preoperative optimization Cook DJ, Geriatric Anesthesia, New Frontiers in Geriatrics Research; AGS, 2004 p16 Rosenthal RA, Kavic SM, Assessment and management of the geriatric patient. Crit Care Med 2004, Vol 32, No 4 ( Suppl)

  7. Pre-op Evaluation • Health………….…H&P, Lab, Tests Intermediate/high risk:………. CBC, CMP,EKG, UA, CXR Low risk……………………………Indicated by conditions (usually no testing is needed*) • Cognitive …………..3 item recall , if fails, do MMSE • Nutritional Intermediate/high risk ………History, Albumin, BMI • Functional ………….Cardiac & Activities of Daily Living (ADLs) ( Cardiac evaluation will be covered in modules 2 & 3) *Stein et al; NEJM 2000; 342: 168 Anesth 2002; 96:485-496 Geriatrics at Your Finger Tips 2005, 7th edition

  8. TESTS AS INDICATED BY C0NDITIONS orAGE Minimally invasive (cataracts, diagnostic arthroscopy): no tests. Moderately invasive : use judgment X= indicated ASA refresher course 2001

  9. Post-op Mortality Cause % Cardiac 12-32 % Pulmonary 28-62 % Sepsis 15-28 % Cancer 6-18 % Renal Failure 3-8 % King MS Preoperative Evaluation AAFP July 15 2000vol. 62, No 2 The approach in the H&P Focus on the prevention of the causes of morbidity, mortality and increased LOS. Cardiac Pulmonary Renal Sepsis prevention Epidemiology (continued)

  10. 28-62 % of all Post-Op mortalities Of this: 25-56% due to pneumonia 3-38% due to pulmonary embolus Risk factors: COPD/RAD Smoker ( 20 pk/yrs) morbid obesity abdominal/thoracic procedure pre-op URI Anesthesia > 3 hrs. NG tube post-op. Smetana GW, Preoperative Pulmonary Evaluation, Vol. 340, Number 12, NEJM March 25 1999 T Pulmonary

  11. Pulmonary ABG’s----poor predictors • Only if PCo2 > 45 (at baseline)= poor outcome PFT’s (pre-op)--only helpful in: • 1) Lung resection----to predict post op course. • 2) COPD/Asthma----to evaluate if at optimum broncho-dilatation Suggested Pre-OP Pulmonary Evaluation : • ABG’s in severe lung disease • PFT’s in anticipated lung resection or assess level of broncho dilatation Kearney DJ, Thomas HL, Reilly JJ, et al. Assessment of operative risk in patients undergoing lung resection. Chest /105/3 March 1994

  12. PRE-OP PULMONARYMANAGEMENT: Maximize lung function: (this applies mostly to abd/thrx procedures) In COPD or RAD: • Bronchodilators and steroids; (inhaled & ? oral), to reach goal of; free of wheezing and peak flow > 80% of predicted or personal best. • D/C smoking for eight weeks in abd or thoracic procedures • Weight loss in obese • Warn patient to call in if developing URI in immediate pre-op • Urge avoidance of NG’S as much as possible • Chest physiotherapy in elective Major abdominal and thoracic surgery (Deep breathing, early mobilization ) • Intermittent and continuous positive pressure treatments for pulmonary high risk patients unable to perform deep breathing exercises or incentive respirometry. • DVT PROPHYLAXIS Fagivik OM, Hahn I et al. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery Br. J. Surg 1997; 84: 1535-1538 Celli BR, Rodriquez KS, Snider GL. A controlled trial of intermittent positive pressure breathing , incentive respirometry and deep breathing exercises in prevention of pulmonary complications after abdominal surgery. Am Rev. Respir Dis. 1984; 130:12-5 Stock MC, Downs JB, Gauer PK, et al. Prevention of postoperative pulmonary complications with CPAP, incentive spirometry and conservative therapy. Chest 1985 ;87:151-7

  13. RENAL PRE-OP EVAL in at Risk: Risk factors: PVD HTN DM Previous Renal Dz. Recent IV contrast dye Recent Hypovolemic or hypotensive incident PRE-OP tests: UA CR/BUN, Lytes PRE-OP MANAGEMENT optimal hydration avoidance of hypotension and hypovolemia r/o outlet obstruction as indicated (PVR) drug dosage adjustment SEPSIS PRE-OP EVAL: UA CXR URI screen in immediate pre-op. PRE-OP MANAGEMENT treat all infections and allow adequate time for clearance before procedure URI screen in immediate pre-op. Delirium See delirium lectures and pearl card at geriatrics.unmc.edu and go to GERI pearls

  14. MANAGEMENT OF OTHER CARDIOVASCULAR CONDITIONS BLOOD PRESSURE: If BP > 180 systolic or >11O mm Hg diastolic pre-op must be controlled before surgery • Both absolute elevation and great fluctuations in BP are associated with myocardial ischemia(Beta blockers are preferred) Reminder to patients: Take antihypertensives PO on day of surgery with sip of water.

  15. Beta-Blockade For Intermediate and high cardiac event risk The following recommendations are derived from these studies: 1) No one b-blocker better than another The following have been studied: • atenolol 5 -10 mg IV 30 min pre-op, then 50 -100 mg q d for 7days or more • bisprolol 5-10 mg a day, 30+days pre op then continue 30 days post-op • labetolol 100 mg a day pre-op and continue post op. • esmolol IV 1 hr preop, then metoprolol q am on 1st postop day,continue until discharge 2) Do not discontinue immediately post-op. Most protocols continue for at least 30 days post-op 3) Titrate dose of drug to heart rate 55 - 65 bpm. Perioperative atenolol in noncardiac surgery. NEJM 1996;335:23 Mangano DT, Layug EL, et. al. Effect of atenolol on mortality and cardiovascular mortality after noncardiac surgery. Multilcenter study of Perioperative Ischemia Research Group NEJM 1996;335:1713-1720 Poldermans D, Boersma E, et. al;. The effect of bisoprolol on perioperative mortality and myocardial infarction in high risk patient undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation applying Stress Echocardiography Study Group NEJM 199;341:1789-1794 Stone JG, Foex P, et. al. Risk of myocardial ischemia during anesthesia in treated and untreated hypertensive patients Br. J Anaesth, 1988;61:675-0679 Urban MK, Markowitz SM, et. at. Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesht Analg 2000;90:1257-1261 Shammash JB, Trost JC. et al;. Perioperative beta-blocker withdrawal and mortality in vascular surgical patients . Am. Heart J. Soo1;141:148-153

  16. DVT Prophylaxis ÎLDUH : low dose unfractionated heparin ( 5000 u sc q 12 hours) ÏLMWH: low molecular weight heparin Ð Counadin: INR goal of 2-3. ÑRisk for thrombosis Ò Intermittent Pneumatic Compression device (6) SS: Fitted graduated stockings that extends above the knee American College of Chest Physicians Consensus Conference on Antithrombotic TherapyGeerts WH, Heit JA, et. al.. Prevention of venous thromboembolism Chest 2001 119;132S-175SAronow WS, The prevention of venous thromboembolism in older adults: Guidelines. J of Gerontology, MEDICAL SCIENCES 2004, vol 59A, No.1, 42- 47

  17. History Intake Weight loss Albumin Less than 3.3 mg /dl increased LOS, readmits, mortality BMI Less than 20 indicates malnutrition Corti M:. JAMA 1994; 272:1035 Treatment Increased protein Multivitamins & minerals Limit NPO If severe: Consider parenteral? If severe and uncorrectable Discuss risks of poor outcome Chandra RK: Lancet 1992; 340:1124-1127 Van Meyenfeldt MF, Meijerink WJHJ, Rou-flard MJ, et al: Clin Nutr 1992; 11:180-186 Milne AC, Potter J, Avenell A: Cochrane Database of Systemic Reviews 2002; 3:CD003288 Buzby GP: Veterans Affairs NEngl JMed 1991; 325:525-532 Nutritional

  18. ADLs and expectations How to remember the ADLs that will affect my patient. D-E-A-T-H Seymour DG, Pringle R:. Gerontology 1983; 29:262 Rosenthal RA, Kavic SM, Assessment and management of the geriatric patient. Crit Care Med 2004, Vol 32, No 4 ( Suppl) D ress E at A mbulate T ransfer H ygiene FunctionalActivities of Daily Living: ADLs

  19. ADLs and Hospital outcomes • Loss of 1 or more ADL during hospitalization 10% • Discharged without recovery to baseline ADL’s 10% • Pre-hospital independent but post-hospital dependent =75% Reidinger JL, Clinics in Geriatric Medicine. Vol 14, No 4, Nov 1998 Landefeld CS, Geriatric Review Syllabus 5th edition 2002 -2004 pp75-84 Lamont CT. JAGS 1983;31"282-8

  20. Pre-op Evaluation • Health………….…H&P, Lab, Tests Intermediate/high risk:………. CBC, CMP,EKG, UA, CXR Low risk……………………………Indicated by conditions (usually no testing is needed*) • Cognitive …………..3 item recall , if fails, do MMSE • Nutritional Intermediate/high risk ………History, Albumin, BMI • Functional ………….Cardiac & Activites of Daily Living (ADL’s) ( Cardiac evaluation will be covered in modules 2 & 3) *Stein et al; NEJM 2000; 342: 168 Anesth 2002; 96:485-496 Geriatrics at Your Finger Tips 2005, 7th edition

  21. The End of Module One on PREOPERATIVE EVALUATION in the ELDERLY

  22. Post-test A 78-year-old woman with osteoarthritis and a history of peptic ulcer disease is scheduled for total knee replacement. Which of the following perioperative measures is most effective to prevent deep-vein thrombosis (DVT)? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

  23. Which of the following perioperative measures is most effective to prevent deep-vein thrombosis (DVT)? A. Subcutaneous fixed-dose low-molecular-weight heparin B. Subcutaneous adjusted-dose unfractionated heparin C. Subcutaneous low-dose unfractionated heparin D. Oral adjusted-dose warfarin E. Dextran

  24. Answer:A. Subcutaneous fixed-dose low-molecular-weight heparin • Individual studies and a meta-analysis suggest that low-molecular-weight heparin is the most effective pharmacologic method for preventing the development of DVT following total knee replacement. DVT occurs in 40% to 60% of patients following this procedure, and pulmonary embolism occurs in 15%. Low-molecular-weight heparin inhibits clotting indirectly by accelerating the formation of irreversible complexes between antithrombin-3 and several activated clotting factors. An additional advantage is the ease of administration and the lack of the need for laboratory monitoring, as in the use of low-dose warfarin. • Adjusted-dose heparin and adjusted-dose warfarin also decrease the incidence of thromboemboli, but the patient has an increased risk of bleeding and would require frequent monitoring of coagulation factors.

  25. The incidence of bleeding complications with low-molecular-weight heparin generally has been similar to, or slightly lower than, the incidence with standard heparin, and it is lower than with warfarin. Thrombocytopenia, which can develop in patients taking standard heparin, can also develop with low-molecular-weight heparin. For a patient who is recovering from knee replacement surgery, the recommended dosage of enoxaparin, an FDA-approved low-molecular-weight heparin, is 30 mg twice daily by subcutaneous injection for 7 to 10 days. The primary disadvantage of this treatment is that the average wholesale price for this dose greatly exceeds the cost of the equivalent amount of warfarin. In the acute-care hospital, where the savings in decreased laboratory costs are realized by the institution under diagnosis-related group reimbursement, the additional cost is justifiable. In long-term care settings, this cost savings is not available to the nursing facility, so there is significant reluctance to adopt the use of low-molecular-weight heparin over warfarin. • Dextran is not effective in preventing DVT.. However, it has been shown to decrease the incidence of pulmonary embolus. End

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