PREOPERATIVE ASSESSMENT OF THE GERIATRIC PATIENT
PREOPERATIVE
ASSESSMENT OF THE
GERIATRIC PATIENT
Cheryl Hinners M.D.
CASE
– MR. PREOP IS A 75YO WM WITH THE
PMH OF COPD(NO MEDS, CONTINUES TO
SMOKE), DM-2, OA, HTN, AND CAD WITH
AN MI 5 YRS AGO. HE HAS BEEN
DIAGNOSED WITH PROSTATE CA AND
AN OPEN PROSTATECTOMY IS
PLANNED.
– LIVES INDEPENDENTLY, SWING DANCES
2X /WEEK. MEDS; ASA, IBPROFEN, NPH
BID, FELODIPINE
• MORE THAN 50% OF OLDER
AMERICANS WILL HAVE A SURGICAL
PROCEDURE AFTER
AGE 65
• ASA CLASSIFICATIONS
• DECREASED SURGICAL MORTALITY
PREOP ASSESSMENT
• IDENTIFY INCREASE RISK FOR
COMPLICATIONS
• MAKE RECOMMENDATIONS
– COMORBID CONDITIONS
– PHARMACOLOGIC TX
– FUNCTIONAL/PSYCHOLOGIC STATES
ASSESSING RISK OF
CARDIAC COMPLICATIONS
• MOST COMMON AND SERIOUS
• STRONGEST PREDICTORS OF
ADVERSE CARDIAC OUTCOMES
– RECENT MI
– UNCOMPENSATED CHF
– USA
– ARRYTHMIAS
PRACTICE GUIDELINES
MAJOR CLINICAL PREDICTORS
•
USA, CHF, ARRYTHMIAS, SEVERE
VALVULAR DZ
INTERMEDIATE
• MILD ANGINA, PRIOR MI,
COMPENSATED CHF, DM
• MINOR CLINICAL PREDICTORS
– ADVANCED AGE
– ABNORMAL EKG
– ABNORMAL RHYTHM
– LOW FUNCTIONAL CAPACITY(METS)
– H/O STROKE
– UNCONTROLLED HTN
PROCEDURE RISK
• HIGH
– EMERGENT
– MAJOR VESSEL PROCEDURE
– PVD PROCEDURE
– PROLONGED PROCEDURE
• INTERMEDIATE RISK
– CAROTID ENDARTECTOMY
– HEAD AND NECK PROCEDURES
– INTRAPERITONEAL/INTRATHORACIC
– ORTHOPEDIC
– PROSTATE
• LOW RISK PROCEDURES
– BREAST
– CATARACT
– ENDOSCOPIC
MANAGEMENT OF
SELECTED PROBLEMS
• HTN
– DIASTOLIC BP >110 OR MAJOR
FLUCTUATIONS IN BP
– ELEVATED BP
• REVIEW MEDS, CONSIDER AGE-RELATED
CHANGES, VOLUME STATUS, PAIN, FULL
BLADDER.
• CHF
– SIGNIFICANT RF FOR CARDIAC
COMPLICATIONS
– TX OF SYSTOLIC DYSFUNCTION
– MANAGEMENT INTRAOP
• PULMONARY DISEASE
– POSTOP MORBIDITY IN 40% ELDERLY
FROM RESPIRATORY PROBLEMS
– AGE-RELATED CHANGES
– ANESTHESIA
– SURGICAL PROCEDURE
– POSTOP PAIN MEDS
****PREOP FUNCTIONAL LEVEL IS A
RELIABLE PREDICTOR OF
PULMONARY COMPLICATIONS******
• INTERVENTIONS
– SMOKING CESSATION
– COPD CONSIDERATIONS
• DIABETES
– MEDICATION CONSIDERATIONS
• THROMBOEMBOLIC DZ
– OCCUR IN 20-30% OF PATIENTS
UNDERGOING GENERAL SURGERY
– HIGHER INCIDENCE , >40%
• HIP/KNEE
• GYN CA/ OPEN PROSTATECTOMY
• NEUROSURG
• NEUROPSYCHIATRIC DISORDERS
– DEMENTIA
– DELIRIUM
– DEPRESSION EXACERBATION
– ALCOHOLISM
POSTOP PAIN
• PAIN SCALE
• MEDICATIONS
• LAXATIVES
PREDICTORS OF POOR
OUTCOME
• ADVANCED AGE
• POOR FUNCTIONAL STATUS
• IMPAIRED COGNITION
• LIMITED SOCIAL SUPPORT
IATROGENIC ILLNESS
• DVT
• DOSING DRUGS
• DRUG-DRUG INTERATIONS
• PRESSURE ULCERS
• DEHYDRATION
