PREOPERATIVE ASSESSMENT OF THE GERIATRIC PATIENT

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PREOPERATIVE ASSESSMENT OF THE GERIATRIC PATIENT

• Cheryl Hinners M.D.

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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

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• MORE THAN 50 OF OLDER AMERICANS WILL HAVE A
  SURGICAL PROCEDURE AFTER
• AGE 65
• ASA CLASSIFICATIONS
• DECREASED SURGICAL MORTALITY

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PREOP ASSESSMENT

• IDENTIFY INCREASE RISK FOR COMPLICATIONS
• MAKE RECOMMENDATIONS
• COMORBID CONDITIONS
• PHARMACOLOGIC TX
• FUNCTIONAL/PSYCHOLOGIC STATES

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ASSESSING RISK OF CARDIAC COMPLICATIONS

• MOST COMMON AND SERIOUS
• STRONGEST PREDICTORS OF ADVERSE CARDIAC OUTCOMES
• RECENT MI
• UNCOMPENSATED CHF
• USA
• ARRYTHMIAS

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PRACTICE GUIDELINES

• MAJOR CLINICAL PREDICTORS
• USA, CHF, ARRYTHMIAS, SEVERE VALVULAR DZ
• INTERMEDIATE
• MILD ANGINA, PRIOR MI, COMPENSATED CHF, DM

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• MINOR CLINICAL PREDICTORS
• ADVANCED AGE
• ABNORMAL EKG
• ABNORMAL RHYTHM
• LOW FUNCTIONAL CAPACITY(METS)
• H/O STROKE
• UNCONTROLLED HTN

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PROCEDURE RISK

• HIGH
• EMERGENT
• MAJOR VESSEL PROCEDURE
• PVD PROCEDURE
• PROLONGED PROCEDURE

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• INTERMEDIATE RISK
• CAROTID ENDARTECTOMY
• HEAD AND NECK PROCEDURES
• INTRAPERITONEAL/INTRATHORACIC
• ORTHOPEDIC
• PROSTATE

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• LOW RISK PROCEDURES
• BREAST
• CATARACT
• ENDOSCOPIC

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MANAGEMENT OF SELECTED PROBLEMS

• HTN
• DIASTOLIC BP gt110 OR MAJOR FLUCTUATIONS IN BP
• ELEVATED BP
• REVIEW MEDS, CONSIDER AGE-RELATED CHANGES, VOLUME
  STATUS, PAIN, FULL BLADDER.

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• CHF
• SIGNIFICANT RF FOR CARDIAC COMPLICATIONS
• TX OF SYSTOLIC DYSFUNCTION
• MANAGEMENT INTRAOP

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• PULMONARY DISEASE
• POSTOP MORBIDITY IN 40 ELDERLY FROM RESPIRATORY
  PROBLEMS
• AGE-RELATED CHANGES
• ANESTHESIA
• SURGICAL PROCEDURE
• POSTOP PAIN MEDS

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• PREOP FUNCTIONAL LEVEL IS A RELIABLE
  PREDICTOR OF PULMONARY COMPLICATIONS

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• INTERVENTIONS
• SMOKING CESSATION
• COPD CONSIDERATIONS

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• DIABETES
• MEDICATION CONSIDERATIONS

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• THROMBOEMBOLIC DZ
• OCCUR IN 20-30 OF PATIENTS UNDERGOING GENERAL
  SURGERY
• HIGHER INCIDENCE , gt40
• HIP/KNEE
• GYN CA/ OPEN PROSTATECTOMY
• NEUROSURG

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• NEUROPSYCHIATRIC DISORDERS
• DEMENTIA
• DELIRIUM
• DEPRESSION EXACERBATION
• ALCOHOLISM

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POSTOP PAIN

• PAIN SCALE
• MEDICATIONS
• LAXATIVES

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PREDICTORS OF POOR OUTCOME

• ADVANCED AGE
• POOR FUNCTIONAL STATUS
• IMPAIRED COGNITION
• LIMITED SOCIAL SUPPORT

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IATROGENIC ILLNESS

• DVT
• DOSING DRUGS
• DRUG-DRUG INTERATIONS
• PRESSURE ULCERS
• DEHYDRATION