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Goals. To describe the purpose of the preoperative assessment To provide strategies to minimize operative risks . The Big Question: Should this patient go for surgery ?. - goal of surgery - urgency of surgery ( elective, urgent, emergent) - patient’s/family’s goals and wishes - PowerPoint PPT Presentation
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UMMS CRIT Module I: Preoperative Assessment in the Older Adult
Petra Flock, MD, MSc, CMDDivision of GeriatricsUniversity of MassachusettsMedical School
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• To describe the purpose of the preoperative assessment• To provide strategies to minimize operative risks
Goals
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
- goal of surgery
- urgency of surgery (elective, urgent, emergent) - patient’s/family’s goals and wishes
- baseline function, co-morbidities
- life expectancy
- anticipated outcomes/complications
The Big Question:Should this patient go for surgery?
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Not just for “clearance”• To identify factors associated with increased risks of specific
complications related to a procedure• To recommend a management plan to minimize these risks
Preoperative Assessment -Purposes
Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric Medicine: An Evidence Based Approach, 4th ed. New York: Springer; 2003.
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Delirium• Infection• Pressure sores• Malnutrition• Functional decline
increased mortalitypoorer quality of lifeneed for increased care/change of place of living
What Do Geriatricians Worry About?
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Organ reserves are diminished• Complications are more likely• Less is often more• Test only what you are able and prepared to correct and what will
improve outcome• You minimize complications, if you prevent prolonged bed rest
(pre- and post-op)
Common Sense Geriatric “Rules”
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Functional Assessment• Cognitive Assessment• Nutritional Assessment• Review of advance directives
Preoperative Assessment - Components
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• American Society of Anesthesiologists (ASA) score– Class I A normal healthy patient for elective operation– Class II A patient with mild systemic disease– Class III A patient with severe systemic disease that limits
activity but is not incapacitating– Class IV A patient with incapacitating systemic disease that is a
constant threat to life– Class V A moribund patient that is not expected to survive 24 hrs
with or without the operation
Functional Assessment
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Dementia and Hx of delirium are major predictor of post-op delirium
• Patients with delirium have higher mortality• Know your patient’s baseline cognitive function (Mini-Cog,
CAM, etc.)
Cognitive Assessment
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Poor nutrition is a risk factor for – pneumonia– poor wound-healing– 30-day mortality
• Hypoalbuminemia (<3.3mg/dL)– increased length of stay– increased rates of readmission– unfavorable disposition – increased all-cause mortality
Nutritional Assessment
Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994;272:1036.
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Routine screening is low yield– Pre-op testing should be based on the type and urgency of
surgery• Manage hypertension
– lower blood pressure to under 180/110• Avoid long periods without nutrition• Treat easily reversible factors (anemia, infection, etc)• Use ß-blockers peri-operatively for major surgery, if not contra-
indicated
Strategies to Minimize Risk - pre-operative
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Control diabetes without causing hypoglycemia• Pay attention to constipation/urination• Mobilize early/DVT prophylaxis• Minimize use of psycho-active medication• Control pain (your dementia patient won’t do PRN well)• Avoid prolonged periods without nutrition• Involve the families
Strategies to Minimize Risk - post operative
UMMS CRIT 2010 Module I: Pre-Operative Assessment
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Older adults have decreased reserves in multiple organ systems• Disease burden and functional capacity outweigh age when
assessing preoperative risk• Collaboration among providers helps to identify functional,
cognitive and nutritional deficits/risks and to create management plans to minimize these deficits/risks when possible
Summary