Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the ACS NSQIP/American Geriatrics Society Sanjay Mohanty, MD; Ronnie A. Rosenthal, MS,MD; Marcia M. Russell, MD; Mark D. Neuman, MD, MSc; Clifford Y Ko, MD, MS, MSHS; Nestor F. Esnaola, MD, MPH, MBA
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Establishing Guidelines for Geriatric Surgical Care Preoperative Assessment Intraoperative Management Postoperative Care Discharge Planning Developing Quality Indicators for Elderly Surgical Patients. McGory (Russell) & Ko, Ann Surg 2009
Establishing Guidelines for Geriatric Surgical Care Preoperative Assessment Intraoperative Management Postoperative Care Discharge Planning Developing Quality Indicators for Elderly Surgical Patients. McGory (Russell) & Ko, Ann Surg 2009
Chow et al JACS, 2012
Preoperative Assessment Cognition, Function, Nutrition and Frailty Comorbidity Assessment Medication Use Provider and Patient Discussions Discharge Planning
Establishing Guidelines for Geriatric Surgical Care Preoperative Assessment Intraoperative Management Postoperative Care Discharge Planning
Methods Focused, structured search of MEDLINE(1995-2014) to identify systematic reviews meta-analyses practice guidelines clinical trials 28-member, multidisciplinary expert panel: American College of Surgeons (ACS) ACS Geriatric Surgery Task Force American Society of Anesthesiologists American Geriatrics Society (AGS) AGS Geriatrics for Specialists Initiative Mohanty et al, JACS 2016
Perioperative Geriatric Care Immediate Preoperative Period Intraoperative Management Postoperative Care Care Transitions
Immediate Preoperative Goals / Advanced Care Planning Preoperative Preparations
Treatment Goals and Expectations Patient expectations are influenced by their treatment preferences. Older patients are less likely to want a treatment (even if it results in cure) that may result in severe functional or cognitive impairment. Fried TR, Bradley EH, Towle VR, Allore H. N Engl J Med. 2002;346:1061-66.
Percent of Patients Who Want the Treatment Return to Current Health Functional Impairment Cognitive Impairment Low Burden Treatment High Burden Treatment 98.7% 88.8% Fried TR, Bradley EH, Towle VR, Allore H. N Engl J Med. 2002;346:1061-66.
What percent of older adults do you think would accept a low burden treatment (possibly for cure) if there was a chance it might result in a severe functional deficit? A. 85% B. 65% C. 45% D. 25%
Percent of Patients Who Want the Treatment Return to Current Health Functional Impairment Cognitive Impairment Low Burden Treatment High Burden Treatment 98.7% 25.6% 11.2% 88.8% Fried TR, Bradley EH, Towle VR, Allore H. N Engl J Med. 2002;346:1061-66.
For Patients with Pre-existing Advance Directives: Required Reconsideration New risks, benefits, and alternatives of procedure should be discussed Ensure that approach to potential lifethreatening problems is consistent with values American College of Surgeons, 2014; American Nurses Association, 2012; American Society of Anesthesiologists, 2008
From: BPG Preoperative Assessment 2012
Discontinue Potentially Inappropriate Medications J Am Geriatr Soc. 2015 Nov;63(11):2227-46.
Intraoperative Management Anesthetic Approach Perioperative Analgesia Plan Preventing Postop Nausea and Vomiting Patient Safety in the OR Preventing Complications Fluid Management
Physiologic Effects of Anesthesia Medications Changes in: Systemic Vascular Resistance Cardiac Preload Baroreceptors Responses Lung Mechanics Oxygen Diffusion Neurotransmitter Function End Organ Blood Flow
Physiologic Changes of Aging
Anesthesia in the Older Adult There is insufficient evidence to recommend a single best anesthetic plan for all older adults.
Role of Regional Techniques for Anesthesia
Perioperative Analgesia in the Older Adult Directed pain history and physical Appropriately titrated for increased sensitivity Include a prophylactic bowel regimen Avoid inappropriate medications (benozos, meperidine, benadryl, Beers list,) Multimodal Use opioid-sparing and regional techniques
Role of Regional Techniques for Perioperative Pain
Preventing Postoperative Nausea and Vomiting
Pulmonary Considerations
Fluid Management in the Older Adult There is insufficient evidence to recommend a single best intraoperative fluid management plan for all older adults.
Fluid Management
Postoperative Care Controlling Perioperative Acute Pain Delirium/ Cognitive Issues Functional Decline Fall Risk Pressure Ulcer and UTI Prevention Adequate Nutrition Pulmonary Complications
Perioperative Analgesia in the Older Adult Directed pain history and physical Appropriately titrated for increased sensitivity Include a prophylactic bowel regimen Avoid inappropriate medications (benozos, meperidine, benadryl, Beers list,) Multimodal Use opioid-sparing and regional techniques
Precipitating Factors for Delirium Pain Medications Dehydration Under-nutrition Unfamiliar environment Sleep disruption Sensory deprivation Restraints Catheters & other devices Constipation Urinary retention Physiolgic stress of surgery Infection Hypoxemia Electrolyte imbalance Neurological events Major organ dysfunction
Which of the following drugs is the best first line treatment for delirium in the postoperative period? A. Lorazepam B. Diphenhydramine C. Haloperidol (low dose) D. None of the above
Perverse Incentives Definition: an incentive that has an unintended and undesirable result which is contrary to the interests of the incentive makers. Fall in hospital = Never Event Prevent falls = Keep patient in bed
Functional Decline and Deconditioning For every day an older adult is immobilized, it takes at least three days to regain lost function. For older adult surgical patients, one in four experiences a significant decline in function by hospital discharge and 60% experience some loss of independence* *Berian et al. JAMA Surg preprint on line July 2016
Nutritional Status of Older Adults Living in the Community or in Nursing Homes Community dwelling elders: 40 % are either malnourished or at risk Nursing home residents: Two thirds are either malnourished or at risk Kaiser MJ, 2010
Factors Associated with Swallowing Dysfunction and Aspiration Pneumonia Disease Related Factors Prior Stroke Neuromuscular disease GERD Incidence of Postop Aspiration Pneumonia with Age Iatrogenic Factors ET tubes Esophageal temp probes NG tubes TEE probes Medications KozlowJH, et al. Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999-2000. Crit Care Med 31:1930-1937, 2003.
Transitions of Care Assess Social Support /Home Health Needs Complete Medication Review Pre-Discharge Geriatric Assessment Formal Written Discharge Instructions Communication with Primary Physician
Pre-Discharge Geriatric Assessment Cognition Status Presence of delirium Functional Status Mobility Fall Risk Nutritional Status Including access
Acknowledgements Sanjay Mohanty, MD (James C Thompson Geriatric Fellow at ACS) John A. Hartford Foundation American Geriatrics Society Geriatrics for Specialists Initiative American Society of Anesthesiologists American College of Surgeons NSQIP https://www.facs.org/quality-programs/acsnsqip/geriatric-periop-guideline Google ACS Perioperative Guidelines.