Geriatric Grand Rounds May 21, 2015 - University of · PDF file · 2015-05-21Geriatric Grand Rounds May 21, 2015 ... ASA Classification of Physical Status ... 05/21/2015 23 Functional

05/21/2015

1

PreoperativeAssessmentoftheGeriatricPatient

KelseyWalker,MD

GeriatricGrandRounds

May21,2015

ObjectivesIntroduction:whydoesitmatter?

Reviewtraditionaltoolstoassesspreoperativerisk:valueandlimitations

Identifygeriatricspecificriskpredictorsforadversesurgicaloutcomes

Describeoptionsforproactiveperioperativemanagementstrategies

05/21/2015

2

ObjectivesIntroduction:whydoesitmatter?Reviewtraditionaltoolstoassesspreoperativerisk:valueandlimitations



Whydoesitmatter?

2010USCensus

05/21/2015

3

Whydoesitmatter?

Normalage‐relatedphysiologicchangeslimitphysiologicreserveofolderpatients

Increasedvulnerabilitytopostoperativestressandillness

Whydoesitmatter?PerioperativeComplications

30‐DayMortalitybyTypeofOperation

<80 yearsold >80yearsold

Alloperations 2.8% 8.2%

Generalsurgery

4.3% 11.4%

Vascularsurgery

4.1% 9.4%

Thoracicsurgery

6.3% 13.5%

Orthopedicsurgery

1.2% 8.3%

SurgicalMorbidity

<80 yearsold >80yearsold

> 1complication 12.1% 20%

Pneumonia 2.3% 5.6%

UTI 2.2% 5.6%

Required intubation 1.6% 2.8%

Progressiverenalfailure

0.4% 1.0%

Myocardialinfarction

0.4% 1.0%

Cardiacarrest 0.9% 2.1%HamelJAGS2005

05/21/2015

4

Significanceofdischargetoinstitutionalcarefacility

Legner etal.Annsurg.2009

ComponentsofaPreoperativeAssessment

Assessmentofhealthstatus

Riskdetermination

ClearancevsOptimization

Developmentofperioperativecareplan

Patienteducation

05/21/2015

5

Harvey76y/omalepresentingforpreoperativeevaluationfortotalkneearthroplasty(TKA)

Medicalhistory:

Hypertension

Atrialfibrillation

Diabetes

Hyperlipidemia

Osteoarthritis

SocialHistory:

Nonsmoker,socialetoh

Widowed,livesalonein2storyhome

Medications:

Metoprolol 25mgBID

Atorvastatin 40mgdaily

Warfarin 5mgdaily

Insulinglargine 15unitsQHS

Metformin 500mgBID

Acetaminophen1000mgq8hoursPRNpain

05/21/2015

6

PhysicalExam

Vitals:temp97.9F,pulse88,BP152/84,O296%RA,BMI20

General– well‐groomed.Ambulateswithslowantalgicgaitwiththeuseofacane.

CV‐ irregularlyirregular,nomurmur Pulm‐ lungsclear Abdomensoft,nt/nd Extremitieswithoutedema,braceonrightknee

Ancillarytests

Labs H/H:11.5/35.5;INR2.3 Creatinine1.1,fastingbloodglucose115,A1C7.2% Albumin2.9EKG‐ atrialfibrillation,normalaxis,normalintervals,noqwaves

05/21/2015

7


ReviewtraditionaltoolstoassesspreoperativeriskIdentifygeriatricspecificriskpredictorsforadversesurgicaloutcomes


ASAClassificationofPhysicalStatus

ASAI Healthy

ASA 2 Mildsystemicdiseaseonlywithoutsubstantivefunctionallimitations

ASA 3 Severesystemicdisease,substantivefunctionallimitations;oneormoremoderatetoseverediseases

ASA 4 Severesystemicdiseasethatisaconstantthreattolife

ASA5 Moribound patientnotexpectedtosurvivewithout operation

http://www.asahq.org/resources/clinical‐information/asa‐physical‐status‐classification‐system

05/21/2015

8

Assessingcardiovascularrisk

Mostdevelopedandinvestigated

Incidence

perioperativecardiaccomplicationrates:2%inunselectedpatients

>5%inhigh‐riskpatients

25‐30%postoperativedeathsarefromcardiaccauses

RevisedCardiacRiskIndex(RCRI)

Publishedin1999

Derivedfrom2893patientsundergoingelectivemajornoncardiacprocedures

Validatedincohortof1422similarindividuals

Outcome:riskofcardiaccomplications

Leeetal.Circulation.1999

05/21/2015

9

Cardiacrisk:RCRIHistoryofmyocardialinfarction

Historyoforcurrentangina

Useofsublingual nitroglycerine

Positive exercisetestresults

Qwavesonelectrocardiogram

Patientswhohaveundergonepercutaneoustransluminalcoronaryangioplastyorcoronaryarterybypassgraftsurgeryandwhohavechestpainpresumedtobeofischemicorigin

History oftransientischemicattack

Historyofcerebrovascular accident

Diabetesmellitusrequiringinsulin therapy

Chronicrenalinsufficiency, definesasabaselinecreatininelevelofatleast2.0mg/dL

Leeetal.Circulation.1999

Cardiacrisk:RCRI

Riskofcardiaccomplications

Noriskfactors:0.4%

Oneriskfactor1%

2riskfactors:2.4%

Threeormore:5.4%

05/21/2015

10

AssessingCVrisk:Harvey

Riskofcardiaccomplication:1%

GuptaMICANSQIPdatabaserisktool

2011

Developedfrom>200,000patientsundergoingsurgery

Validatedin2008on>250,000patients

Outcomes

Intraoperative/postoperativemyocardialinfarction

Cardiacarrest

Guptaetal.Circulation.2011

05/21/2015

11

Cardiacrisk:NSQIPtool

Riskfactors

Typeofsurgery

Dependantfunctionalstatus

Abnormalcreatinine

ASAclass

Increased age

Guptaetal.Circulation.2011


RiskofMICA:0.76%

05/21/2015

12

RCRI NSQIP‐ gupta

Methodology Prospectivecohort HistoricalcohortusingNSQIPdatabase

PatientPopulation 4315,>=50yrs,onehospital

468,795,>16yrs, 200hospitals

Dateofdevelopment 1989‐1994 2007‐2008

Outcomes In‐hospital MI(CK),pulmonaryedema,completeheartblock,cardiacarrest,cardiacdeath

MI(troponin)andcardiacarrest

Surgeryspecific No yes

ComparisonofRCRIandNSQIP

Cardiacriskbasedonprocedure

Fleisher.Circulation.2007

RiskStratification Procedure Example

Vascular(reportedcardiacriskoften>5%)

•Aorticandothermajor vascularsurgery•Peripheralvascularsurgery

Intermediate(reportedcardiacriskgenerally1%5%)

• Intraperitonealandintrathoracicsurgery

• Carotidendarterectomy• Head andnecksurgery• Orthopedicsurgery

Low(reportedcardiacriskgenerally<1%

• Endoscopicprocedures• Superficial procedure• Cataractsurgery• Breastsurgery• Ambulatorysurgery

05/21/2015

13


05/21/2015

14


Functionalcapacity 14METs— standardlighthomeactivities,walkaroundthehouse,walk12blocksonlevelground

59METs— climbaflightofstairs,walkuphill,walkonlevelgroundbriskly,runashortdistance

>10METs— strenuoussports,heavyprofessionalwork

Fleisher.Circulation.2007

05/21/2015

15

AssessingPulmonaryRisk

Postoperativepulmonarycomplicationrate:6.8%

15%inage>70

Associatedwithlong‐termmortalityinelderlypatientsundergoingnoncardiac surgery

05/21/2015

16

Assessingpulmonaryrisk

Multiplecalculators

ARISCAT—overallrisk

Guptariskcalcucator forpostoperativepneumonia

Guptariskcalculatorforpostoperativerespiratoryfailure

Arozullah index—primarilyresearchoriented

ARISCATRiskIndex

05/21/2015

17

AssessingPulmonaryrisk:Harvey

= 24

AssessingPulmonaryRisk:Harvey

ARISCATriskofpulmonarycomplication:

13.3%

05/21/2015

18

Pulmonaryrisk

Interventions

OptimizationofasthmaandCOPD

Smokingcessation

Preoperativeinspiratorymuscletraining

Chowetal.JAmColl Surg.2012

HarveygoestotheOR

Harveydiscontinuedhiswarfarin5dayspriortosurgeryandisbridgedwithLMWH

Beta‐blockerandstatincontinued

Insulinandmetformin heldonthedayofsurgery

HarveyistakentotheOR,uncomplicatedTKA

05/21/2015

19

Harvey—postop

Post‐operativecourseiscomplicatedbypoorlycontrolledpainandconstipation

POD#2Harveybecomesdelirious…

…sitter,haloperidol,urinaryretention,catheter,pulledoutcatheter,hematuria,reinserted,UTI/sepsisandslowrehab

Dischargedtosub‐acuterehabonPOD#10stillconfused

Couldthishavebeenanticipated?

Traditionalpreoperativeevaluationstrategiesrisk‐stratifypatientsprimarilybasedonasingle‐organsystem

Outcomes:cardiacandpulmonarycomplications,organspecificmortality

05/21/2015

20

Butwhatabout…

Othercomplications—delirium,woundinfections,etc?

Functionalrecovery?

Needforinstitutionalization?

Lengthofstay?

Mortality?

Objectives

Introduction:whydoesitmatter?


IdentifygeriatricspecificriskpredictorsforadversesurgicaloutcomesDescribeoptionsforproactiveperioperativemanagementstrategies

05/21/2015

21

Geriatricriskmeasures

Frailty

Functionalstatus/mobility

Cognition

Nutritionalstatus

Depression

Frailty

Stateofdecreasedphysiologicreserveandresistancetostressorsincreasedvulnerability

05/21/2015

22

Definingfrailty

Score

0‐1 Robust

2‐3 Pre‐frail

4‐5 frail

Frailtyasapredictorofsurgicaloutcomes

Increasedriskofsurgicalcomplications(OR2.54)

Increasedlengthofstay

Incidencerateratioof1.69

Increasedriskofdischargetoassisted‐livingfacilityafterpreviouslylivingathome

Pre‐frail:OR3.15;frailOR20.48

Makary.AnnSurg.2010

05/21/2015

23

Functionalstatusandmobility

Poorfunctionalstatushasbeenassociatedwith:

Postoperativedelirium

Postoperativepulmonarycomplications

SurgicalsiteinfectionswithMRSA

Postoperativenursinghomeplacement

Mortality

Chowetal.JAmColl Surg.2012Kimetal.Clin Interv Aging.2015

Prognosisrelatedtofunctionalstatus

Score 1‐yearmortality

0‐2 62%

3‐5 42%

6‐8 26%

9 11%

Mobility Nodifficulty Withanaid

Withhelpfromanotherperson

Notatall

Abletogetaboutthehouse

3 2 1 0

Abletogetoutofthehouse

3 2 1 0

Abletogoshopping

3 2 1 0

ParkerandPalmer.JBJS.1993

05/21/2015

24

Mobilityandriskofadverseoutcomes

Legner etal.AnnSurg.2004

Assessingcognition

Common– Cognitiveimpairment22%

Dementia13% Increasedriskfor: Postoperativedelirium Postoperativepulmonarycomplications Longerhospitalstays Perioperativemortality Postoperativefunctionaldecline

Chowetal.JAmColl Surg.2012

05/21/2015

25

Assessingcognition

ConsiderscreeningallpatientswiththeMini‐Cog

Carefuldocumentationofpreoperativecognitivestatusmayhelpwithassessmentofpostoperativecognitivechanges

AssessingNutritionalStatus

Malnutritioniscommon:

5.8%communitydwellers

13.8%innursinghomes

38.7%hospitals

50.5%inrehabilitation

Increasedriskofmorbidity(particularyinfections)OR2.30‐3.47

05/21/2015

26

AssessingNutritionalStatus

Severenutritionalriskbasedon

BMI<18.5

Serumalbumin<3.0

Unintentionalweightloss

Ifpossible,considerpreoperativenutritionalassessmentbydietician

Depression

PrevalenceinUSgeriatricpopulation(>70)11%

Preoperativedepressionhasbeenassociatedwith

Increasedmortality

Increasedlengthofstay

Higherpainperceptionandincreasedanalgesicuse

05/21/2015

27

Harvey

FurtherhistoryrevealsthatHarveywaspreviouslyabletowalk2‐3blockswithacaneandclimb1flightofstairs;ambulationwasslowandlimitedbykneepain.Had12lbs ofunintentionalweightlossoverthelastyear;sonexpressesconcernaboutdepressionasHarveyfrequentlycomplainsoffatigueandweakness.Heisstilldrivingthoughrequiresassistancefromfamilymemberswithgroceryshopping.Sonhadbeenmanagingallfinancesduetoerrorsmadeonhis2014taxreturn.

Harvey

FurtherhistoryrevealsthatHarveywaspreviouslyabletowalk2‐3blockswithacaneandclimb1flightofstairs;ambulationwasslowandlimitedbykneepain.Had12lbs ofunintentionalweightlossoverthelastyear;familynoteshefrequentlyendorsesafeelingofgeneralfatigueandweakness.Isstilldrivingthoughrequiresassistancefromfamilymemberswithgroceryshopping.Sonhadbeenmanagingallfinancesduetoerrorsmadeonhis2014taxreturn.

Frailty

05/21/2015

28

Harvey

FurtherhistoryrevealsthatHarveywaspreviouslyabletowalk2‐3blockswithacaneandclimb1flightofstairs;ambulationwasslowandlimitedbykneepain.Had12lbs ofunintentionalweightlossoverthelastyear;familynoteshefrequentlyendorsesafeelingofgeneralfatigueandweakness.Isstilldrivingthoughrequiresassistancefromfamilymemberswithgroceryshopping.Sonhadbeenmanagingallfinancesduetoerrorsmadeonhis2014taxreturn.

Cognition

Mobility

Harvey

FurtherhistoryrevealsthatHarveywaspreviouslyabletowalk2‐3blockswithacaneandclimb1flightofstairs;ambulationwasslowandlimitedbykneepain.Had12lbs ofunintentionalweightlossoverthelastyear;sonexpressesconcernaboutdepressionasHarveyfrequentlycomplainsoffatigueandweakness.Heisstilldrivingthoughrequiresassistancefromfamilymemberswithgroceryshopping.Sonhadbeenmanagingallfinancesduetoerrorsmadeonhis2014taxreturn.

Nutrition

Depression

05/21/2015

29

Harvey

Harvey’ssoncalls.HenotifiesyouthatgivenHarvey’spoorprogresswiththerapytherecommendationhasbeenmadefordischargetoanursinghomefor24hourcare.

“Couldthishavebeenprevented?”





05/21/2015

30

Pre-OpVisit

Operation HospitalOutcomes

30-DayOutcomes

One-YearOutcomes

Prehabiliation

Prehabilitation

Time

ReserveCapacity

CriticalZone

Operation

Theconceptofprehabilitation

05/21/2015

31

Puttingitalltogether

GeriatricSurgicalAssessmentPredicts:

Increasedcomplications

Longerlengthofstaty

Higherrateofdischargeinstitutionalization

Increasedthirtydayre‐admission

Higherhospitalcosts

Highersix‐monthhealthcarecosts

Robinson.AnnSurg.2009Robinson.JAmColl Surg.2011.Robinson.AmJSurg .2011.

05/21/2015

32

Mytake‐homepointsThepreoperativeassessmentisBIG!

Geriatricassessmentmarkerspredictriskforadverseoutcomes

Thisiskeyinanticipatoryguidanceandincounsellingpatientswhoareconsideringundergoinganelectiveprocedure

Prehabilitation mayimprovepost‐operativeoutcomes

Acknowledgements

Drs Shea,Bray‐Hall,Lum,Robbins,andHoffmanforreviewingmyslidesandlettingmepractice!

Dr ThomasRobinsonforassistancewithslides

05/21/2015

33

References

2014ACC/AHAGuidelineonPerioperativeCardiovascularEvaluationandManagementofPatients UndergoingNoncardiac Surgery:AReportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines.JAmColl Cardiol.2014;64(22):e77‐e137

Canet J.Predictionofpostoperativepulmonarycomplicationsinapopulation‐basedsurgicalcohort. Anesthesiology.2010;113(6):1338

ChowWB,RosenthalRA,etal.Optimalpreoperativeassessmentofthegeriatricsurgicalpatient:Abestpracticesguidelinefrom theAmericanCollegeofSurgeonsNationalsurgicalqualityImprovementProgramandtheAmericanGeriatricsSociety.JournaloftheAmColl ofSurgeons.2012;215(4):453‐466

CohnSL,FleisherLA.Evaluationofcardiacriskpriortononcardiac surgery.UpToDate.2015Daabiss M.AmericanSocietyofAnaesthesiologists physicalstatusclassification.IndianJAnaesthe.2011;55(2):111‐115GuptaPK,GuptaH,Sundaram A,etal.Developmentandvalidationofariskcalculatorforpredictionofcardiacriskaftersurgery.

Circulation2011;124:381KimS,BrooksA,Groban L.Preoperativeassessmentoftheoldersurgicalpatient:honinginongeriatricsyndromes.Clinical

interventionsinAging.2015;10:13‐27LeeTH,Marcantonio ER,etal.Derivationandprospectivevalidationofasimpleindexforpredictionofcardiacriskofmajor

noncardiac surgery.Circulation.1999;100(10):1043.Legner VJ,Doerner D,etal.Riskfactorsfornursinghomeplacementfollowingmajornonemergent surgery.TheAmericanJournalof

Medicine.2004;117:82‐86Legner VJ,Massarweh NN,etal.Thesignificanceofdischargetoskilledcareafterabdominopelvicsurgeryinolderadults.Annalsof

Surgery.2009;249(2):250‐256Makary MA,Segev DL,etal.Frailtyasapredictorofsurgicaloutcomesinolderpatients.JournaloftheAmericanCollegeofSurgeons.

2010;210(6):901‐908ParkerMJ,PalmerCJ.Anewmobilityscoreforassessingmortalityafterhipfracture.Britisheditorialsocietyofboneand joint

surgery.1993;75(5):797‐798RobinsonTN,Eiseman B,WallaceJI,etal.Redefininggeriatricpreoperativeassessmentusingfrailty,disabilityandco‐morbidity.Ann

Surg.2009;250:449‐99SmetanaGW.Evaluationofpreoperativepulmonaryrisk.UpToDate.2015Xue QL.Thefrailtysyndrome:definitionandnaturalhistory.Clin Geriart Med.2011;27(1):1‐15Zambouri A.Preoperativeevaluationandpreparationforanesthesiaandsurgery.Hippokratia.2007;11(1):13‐21

Documents

Geriatric Grand Rounds May 21, 2015 - University of · PDF file · 2015-05-21Geriatric Grand Rounds May 21, 2015 ... ASA Classification of Physical Status ... 05/21/2015 23 Functional