Preoperative Assessment of Older Adults.ppt

Preoperative Preoperative Assessment of Assessment of Older AdultsOlder Adults

Seki Balogun, MDSeki Balogun, MD

Core Curriculum in Geriatric Core Curriculum in Geriatric MedicineMedicine

February 16, 2004February 16, 2004

““The role of the medical consultant is The role of the medical consultant is to identify the problems, correct the to identify the problems, correct the correctable, and then point out the correctable, and then point out the uncorrectable to the unsuspecting”uncorrectable to the unsuspecting”

- G.E. McElwain, Jr.- G.E. McElwain, Jr.

IntroductionIntroduction

Preoperative assessment in older Preoperative assessment in older patients is important as:patients is important as:

Surgical procedures are more Surgical procedures are more frequent in the elderlyfrequent in the elderly

Surgical rates are 55% higher in Surgical rates are 55% higher in persons over the age of 65persons over the age of 65

40% of admissions of older patients 40% of admissions of older patients to general hospitals are admissions to general hospitals are admissions to surgical servicesto surgical services


Studies evaluating surgical mortality Studies evaluating surgical mortality show that older patients have a show that older patients have a higher mortality rate than younger higher mortality rate than younger patientspatients

Older patients account for 75% of all Older patients account for 75% of all postoperative deaths, increasing postoperative deaths, increasing nearly linearly with each decade of nearly linearly with each decade of ageage


Preop assessment in the elderly is very Preop assessment in the elderly is very complex and sometimes difficult, due to complex and sometimes difficult, due to factors like:factors like:

Frequent coexistence of multisystem Frequent coexistence of multisystem diseasesdiseases

Heterogeneity of the geriatric population, Heterogeneity of the geriatric population, requiring individualized approach for requiring individualized approach for older patient undergoing surgeryolder patient undergoing surgery

As such , there is no simple algorithmic As such , there is no simple algorithmic guideline guideline

Epidemiology of surgical Epidemiology of surgical riskrisk

In the past, higher surgical risk created In the past, higher surgical risk created a reluctance to operate on most older a reluctance to operate on most older patientspatients

As late as 1980, continued reluctance to As late as 1980, continued reluctance to recommend surgery in geriatric patients recommend surgery in geriatric patients was commonwas common

Surgery was often delayed until it was Surgery was often delayed until it was the only option available, as such it was the only option available, as such it was often performed urgently or emergently, often performed urgently or emergently, leading to even poorer outcomeleading to even poorer outcome

EpidemiologyEpidemiology Changes in attitude toward the estimation of Changes in attitude toward the estimation of

surgical risk have occurred over the yearssurgical risk have occurred over the years Decline in overall surgical mortality in the elderlyDecline in overall surgical mortality in the elderly In the 1950s, surgical mortality ranged from 9.2% In the 1950s, surgical mortality ranged from 9.2%

in patients younger than 55 years with cardiac in patients younger than 55 years with cardiac disease to 18% in patients older than 75 yearsdisease to 18% in patients older than 75 years

More recently, mortality in patients with cardiac More recently, mortality in patients with cardiac disease is about 0.9 – 2.4%disease is about 0.9 – 2.4%

This change in mortality is attributable primarily This change in mortality is attributable primarily to improvements in anesthesia and surgical to improvements in anesthesia and surgical expertiseexpertise

EpidemiologyEpidemiology Hence, from the standpoint of risk, Hence, from the standpoint of risk,

surgery can longer be denied solely surgery can longer be denied solely on the basis of ageon the basis of age

Increase in life expectancy over the Increase in life expectancy over the years also has had a profound years also has had a profound impact on evaluating the benefit of impact on evaluating the benefit of surgerysurgery

Prognosis of older patients who Prognosis of older patients who survive surgery is often better than survive surgery is often better than age –matched controlsage –matched controls

Individual risk factorsIndividual risk factors

Patient-specific risk factorsPatient-specific risk factors Age and life expectancyAge and life expectancy Functional Status – Activities of Daily Living Functional Status – Activities of Daily Living

(ADL) scales predict surgical complications(ADL) scales predict surgical complications• Complications have been found to be more Complications have been found to be more

frequent in ‘inactive’ patientsfrequent in ‘inactive’ patients• Medication Use (include Herbal and OTC)Medication Use (include Herbal and OTC)• Obesity Obesity

• Not found to be risk factor for adverse postop outcomesNot found to be risk factor for adverse postop outcomes• Relationship to postop pulmonary complications- Relationship to postop pulmonary complications-

controversialcontroversial

Individual risk factorsIndividual risk factors Neuropsychological StatusNeuropsychological Status Psychological factors predict surgical outcomePsychological factors predict surgical outcome Social support systems and the “will to live,” Social support systems and the “will to live,”

though difficult to quantify are important though difficult to quantify are important predictors of surgical outcomepredictors of surgical outcome

Assessment of preoperative mental status is Assessment of preoperative mental status is critical to understanding the etiology of critical to understanding the etiology of postoperative cognitive statuspostoperative cognitive status

Dementia is a predictor of poor outcome, with Dementia is a predictor of poor outcome, with increased mortality compared to nondemented increased mortality compared to nondemented patientspatients

Postoperative complications also occur more Postoperative complications also occur more frequently in these patients i.e. deliriumfrequently in these patients i.e. delirium

Specific organ system Specific organ system disease factorsdisease factors

Most post operative mortality occur Most post operative mortality occur as a result of:as a result of:

Cardiac complicationsCardiac complications Pulmonary complicationsPulmonary complications Infectious complicationsInfectious complications

Cardiac DiseaseCardiac Disease

Cardiovascular DiseaseCardiovascular Disease the single best predictor of postoperative cardiac the single best predictor of postoperative cardiac

complications is the presence of ischemic heart diseasecomplications is the presence of ischemic heart disease Myocardial infarction (MI) within 3 months of surgery Myocardial infarction (MI) within 3 months of surgery

carries a risk of recurrent infarction or death of 8 – 30% carries a risk of recurrent infarction or death of 8 – 30% perioperatively, the risk decreases to 3.5 – 5% after perioperatively, the risk decreases to 3.5 – 5% after about 6 monthsabout 6 months

Clinical evidence of heart failure and arrhythmia: Clinical evidence of heart failure and arrhythmia: powerful predictor of adverse cardiac eventpowerful predictor of adverse cardiac event

Best strategy for assessment of preoperative cardiac Best strategy for assessment of preoperative cardiac risk remains controversialrisk remains controversial

Prevention of bacterial endocarditis should be addressed Prevention of bacterial endocarditis should be addressed for susceptible patients using standard protocolfor susceptible patients using standard protocol

Cardiac testing in PAD Cardiac testing in PAD prior to noncardiac surgeryprior to noncardiac surgery

Resting EchocardiogramResting Echocardiogram• Quantify valvular dysfunction in pts with Quantify valvular dysfunction in pts with

significant murmursignificant murmur• Evaluate ventricular dysfunction in poorly Evaluate ventricular dysfunction in poorly

controlled CHF or CHF of unknown causecontrolled CHF or CHF of unknown cause EKGEKG

• Useful in detecting silent ischemia in pts Useful in detecting silent ischemia in pts with CADwith CAD

• Arrhythmias : complex ventricular Arrhythmias : complex ventricular arrhythmias predict future cardiac eventsarrhythmias predict future cardiac events

Recommendations for Recommendations for Preop Resting EKGPreop Resting EKG

Class I Class I Recent chest pain or ischemic equivalent in moderate to Recent chest pain or ischemic equivalent in moderate to

high risk patients scheduled for moderate to high risk high risk patients scheduled for moderate to high risk surgerysurgery

Class IIAClass IIA Asymptomatic with DMAsymptomatic with DMClass IIBClass IIB Prior coronary revascularizationPrior coronary revascularization Asymptomatic male > 45 yrs or female >55 yrs with two or Asymptomatic male > 45 yrs or female >55 yrs with two or

atherosclerotic risk factorsatherosclerotic risk factors Prior hospital admission for cardiac diseasePrior hospital admission for cardiac diseaseClass IIIClass III Routine test in asymptomatic subjects undergoing low risk Routine test in asymptomatic subjects undergoing low risk

proceduresprocedures

Eagle KA, Berger PB et al. J Am Coll Cardiology 39:542, 2002

Cardiac testing in PAD Cardiac testing in PAD prior to noncardiac surgeryprior to noncardiac surgery

Stress testing (Exercise or pharmacologic)Stress testing (Exercise or pharmacologic) Useful in:Useful in:

• New, unexplained chest painNew, unexplained chest pain• Status of CAD uncertainStatus of CAD uncertain• Moderate risk for perioperative cardiac Moderate risk for perioperative cardiac

complication (Eagle Class I or II)complication (Eagle Class I or II)• C reactive ProteinC reactive Protein• Risk factor for cardiovascular diseaseRisk factor for cardiovascular disease• Prognostic importance in CADPrognostic importance in CAD• Data from larger studies neededData from larger studies needed

Estimation of Coronary Risk Estimation of Coronary Risk before noncardiac surgerybefore noncardiac surgery

Revised Goldman Cardiac Risk IndexRevised Goldman Cardiac Risk Index Six independent predictorsSix independent predictors

• High risk surgeryHigh risk surgery• Hx of ischemic heart diseaseHx of ischemic heart disease• Hx of heart failureHx of heart failure• Hx of cerebrovascular diseaseHx of cerebrovascular disease• DM with insulin therapy DM with insulin therapy • Preop serum creatinine >2mg/dlPreop serum creatinine >2mg/dl

Revised Goldman Cardiac Revised Goldman Cardiac Risk IndexRisk Index

Risk factorRisk factor

00

11

22

3 or more3 or more

Major complication Major complication RateRate

0.4%0.4%

0.9%0.9%

7%7%

11%11%

Lee TH, Marcantonio ER et al. Circ 100:1043; 1999

Pulmonary DiseasesPulmonary Diseases Increases the risk of postoperative complicationsIncreases the risk of postoperative complications Accounts for 40%of total complications and 20% of deathsAccounts for 40%of total complications and 20% of deaths Risk factors include:Risk factors include:

• Obesity (controversial) Obesity (controversial) • cough, cough, • smoking, smoking, • history of lung disease, history of lung disease, • site of surgery (more complications when surgery is in upper site of surgery (more complications when surgery is in upper

abdomen, close to the diaphragm) abdomen, close to the diaphragm) • prolonged duration of anesthesia (>3 hours) prolonged duration of anesthesia (>3 hours) • repeat surgery within one yearrepeat surgery within one year• Respiratory InfectionRespiratory Infection• Type of anesthesia (general > epidural or spinal )Type of anesthesia (general > epidural or spinal )

• Clinical findings (wheezes, rales, rhonchi, decreased Clinical findings (wheezes, rales, rhonchi, decreased breath sounds) predict postop pulmonary complicationsbreath sounds) predict postop pulmonary complications

Chest X-rayChest X-ray

Add little to clinical evaluation in Add little to clinical evaluation in identifying periop risksidentifying periop risks

May be useful in patients with May be useful in patients with suspected pulmonary disease or suspected pulmonary disease or cardiac diseasecardiac disease

Pulmonary Function TestPulmonary Function Test

Indicated in lung resection surgery Indicated in lung resection surgery In unexplained dyspnea In unexplained dyspnea Maybe used in COPD or Asthma if unable to Maybe used in COPD or Asthma if unable to

determine patient’s best baselinedetermine patient’s best baseline

Arterial blood gas analysis- indicated in:Arterial blood gas analysis- indicated in: Pts undergoing CABG or upper abdominal Pts undergoing CABG or upper abdominal

surgery with a history of tobacco use or surgery with a history of tobacco use or dyspneadyspnea

lung resection surgerylung resection surgery

Strategies To Reduce Strategies To Reduce Postoperative Pulmonary Postoperative Pulmonary

ComplicationsComplications Complications include:Complications include: AtelectasisAtelectasis InfectionsInfections Prolonged mechanical ventilation Prolonged mechanical ventilation

and respiratory failureand respiratory failure Exacerbation of underlying chronic Exacerbation of underlying chronic

lung diseaselung disease BronchospasmBronchospasm

Strategies To Reduce Strategies To Reduce Postoperative Pulmonary Postoperative Pulmonary

ComplicationsComplicationsPreoperative strategiesPreoperative strategies Smoking CessationSmoking Cessation At least 8 weeks before surgeryAt least 8 weeks before surgery Adequate treatment of COPD and Asthma (inhaled ipratropium, inhaled Adequate treatment of COPD and Asthma (inhaled ipratropium, inhaled

beta agonists, corticosteriods)beta agonists, corticosteriods) Delay elective surgery with respiratory infectionsDelay elective surgery with respiratory infections Treat respiratory infectionsTreat respiratory infections Patient education on lung expansion maneuvers (coughing, incentive Patient education on lung expansion maneuvers (coughing, incentive

spirometry)spirometry)

IntraoperativeIntraoperative Minimize duration of anesthesia and surgery (when possible)Minimize duration of anesthesia and surgery (when possible) Choose laparoscopic rather than open abdominal surgeryChoose laparoscopic rather than open abdominal surgery Choose regional, epidural or spinal anesthesia (when possible)Choose regional, epidural or spinal anesthesia (when possible)

PostoperativePostoperative Deep breathing exercisesDeep breathing exercises Epidural anesthesia in lieu of parenteral opioids Epidural anesthesia in lieu of parenteral opioids

Renal DiseaseRenal Disease

Important impact on morbidity and postop Important impact on morbidity and postop coursecourse

Adjust CrCl for age and decrease in muscle Adjust CrCl for age and decrease in muscle massmass

The dosing of medications should be adjusted The dosing of medications should be adjusted appropriatelyappropriately

Preoperative renal status is the best universal Preoperative renal status is the best universal predictor of postop renal failurepredictor of postop renal failure

Risk of renal deterioration postop higher in Risk of renal deterioration postop higher in patients with serum creatinine greater than patients with serum creatinine greater than 1.2mg/dl ( 2.9% vs. 14.4%)1.2mg/dl ( 2.9% vs. 14.4%)

Renal DiseaseRenal DiseaseOther Risk factors for postoperative renal failure:Other Risk factors for postoperative renal failure: rising serum creatinine rising serum creatinine LV dysfunctionLV dysfunction advanced age advanced age decreased serum albumindecreased serum albumin MalignancyMalignancy emergency surgeryemergency surgery vascular surgery, vascular surgery, Preop diuretic, Preop diuretic, hypotensionhypotension

Poor prognostic indicators:Poor prognostic indicators: oliguria, oliguria, urine sediment abnormalities,urine sediment abnormalities, severity of renal failureseverity of renal failure

Attention should be paid to volume statusAttention should be paid to volume statusAvoid use of nephrotoxic medications when possibleAvoid use of nephrotoxic medications when possible

Type of surgeryType of surgery

Important in determining riskImportant in determining risk Elective or emergentElective or emergent Inside or outside body cavityInside or outside body cavity

Emergency versus Elective Emergency versus Elective SurgerySurgery

Older adults undergo 50% of all Older adults undergo 50% of all emergency proceduresemergency procedures

Surgical risk increases tremendously, Surgical risk increases tremendously, especially in the elderlyespecially in the elderly

Mortality rate 20% in older adults Mortality rate 20% in older adults undergoing emergency surgery, undergoing emergency surgery, compared to 1.9% in patients who had compared to 1.9% in patients who had elective surgeryelective surgery

Post-op complications and morbidity Post-op complications and morbidity were also higherwere also higher

Emergency versus Elective Emergency versus Elective SurgerySurgery

Possible reasons: Possible reasons: Surgical disease may have a more sudden Surgical disease may have a more sudden

onset in the elderly or may be more onset in the elderly or may be more difficult to diagnose because of atypical difficult to diagnose because of atypical presentationpresentation

Surgeons are reluctant to operate Surgeons are reluctant to operate electively in older patientselectively in older patients

Older patients are sometimes reluctant to Older patients are sometimes reluctant to undergo any invasive procedure, and wait undergo any invasive procedure, and wait until option of last resort until option of last resort

Body Cavity versus Non-Body Cavity versus Non-Body Cavity SurgeryBody Cavity Surgery

Surgical mortality increases Surgical mortality increases dramatically in thoracic and dramatically in thoracic and abdominal proceduresabdominal procedures

Common surgical Common surgical procedures in older adultsprocedures in older adults

Most common surgical procedures Most common surgical procedures are prostatectomy, coronary artery are prostatectomy, coronary artery bypass grafting, pacemaker bypass grafting, pacemaker implantationimplantation

Others are: angioplasty, Others are: angioplasty, cholecystectomy, eye surgeries, cholecystectomy, eye surgeries, orthopedic, operations on the orthopedic, operations on the nervous system and abdominalnervous system and abdominal

Relatively Safe Relatively Safe ProceduresProcedures

TURP - mortality about 0.2%TURP - mortality about 0.2% Mortality can increase up to 6.3% in Mortality can increase up to 6.3% in

patients older than 80 years or patients older than 80 years or otherwise at high riskotherwise at high risk

Eye Surgeries: Cataract – very safe, Eye Surgeries: Cataract – very safe, likelihood of life threatening postop likelihood of life threatening postop complication is about 1.2%complication is about 1.2%

Relatively risky Relatively risky ProceduresProcedures

Biliary surgery: In patients older Biliary surgery: In patients older than 70, 30 – 50% of than 70, 30 – 50% of cholecystectomies are performed cholecystectomies are performed emergently resulting in up to a 5-emergently resulting in up to a 5-fold increase in mortality compared fold increase in mortality compared to elective surgeryto elective surgery

Other abdominal surgery: older Other abdominal surgery: older patients have an incidence of patients have an incidence of perforationperforation


Cardiovascular Surgery:Cardiovascular Surgery: PTCA – mortality 2 – 6% in patients 60 PTCA – mortality 2 – 6% in patients 60

and above (higher mortality with age)and above (higher mortality with age) CABG: increased mortality can be CABG: increased mortality can be

predicted from the following: emergency predicted from the following: emergency surgery, renal insufficency, severe LV surgery, renal insufficency, severe LV dysfunction, preop hct less than 34%, dysfunction, preop hct less than 34%, COPD, advanced age, MVR, DM, Body COPD, advanced age, MVR, DM, Body weight less 65kg, Aortic stenosis, Strokeweight less 65kg, Aortic stenosis, Stroke


Orthopedic surgeryOrthopedic surgery Hip surgery, especially after falls – one of Hip surgery, especially after falls – one of

the most common in older adultsthe most common in older adults In-hospital mortality in about 4%, 1-year In-hospital mortality in about 4%, 1-year

mortality of about 14 – 17%mortality of about 14 – 17% Frequent complications – DVT (40 – 60% Frequent complications – DVT (40 – 60%

of patients), Pulmonary embolism (20%), of patients), Pulmonary embolism (20%), pressure ulcer (20 – 70%), Urinary pressure ulcer (20 – 70%), Urinary retention (28 – 52%)retention (28 – 52%)

Total knee replacement: relatively safe, Total knee replacement: relatively safe, mortality rates of about 1.5%mortality rates of about 1.5%

Perioperative Medication Perioperative Medication ManagementManagement

Consultants often must decide if Consultants often must decide if chronic medications should be chronic medications should be continued in perioperative periodcontinued in perioperative period


In general:In general: Medications associated with known adverse Medications associated with known adverse

effects if withdrawn abruptly should be effects if withdrawn abruptly should be continued (consider alternative route when continued (consider alternative route when appropriate)appropriate)

Medications that can increase surgical Medications that can increase surgical complications or not essential for short term complications or not essential for short term improvement in QOL should be heldimprovement in QOL should be held

Medications not meeting either criterion will Medications not meeting either criterion will depend on individual physician judgmentdepend on individual physician judgment


Cardiovascular MedicationsCardiovascular Medications Beta-blockersBeta-blockers

• Beneficial effectsBeneficial effects• Recommended in patients at high risk for Recommended in patients at high risk for

cardiovascular diseasecardiovascular disease• Reduce ischemia by decreasing myocardial Reduce ischemia by decreasing myocardial

oxygen demand due to increased stress and oxygen demand due to increased stress and catecholamine releasecatecholamine release

• Reduce risk of perioperative myocardial Reduce risk of perioperative myocardial infarction and deathinfarction and death

• Should be continued in perioperative periodShould be continued in perioperative period

Centrally acting Centrally acting antihypertensives Alpha 2 antihypertensives Alpha 2

agonistsagonists ClonidineClonidine

• May improve outcomes May improve outcomes • Data less conclusiveData less conclusive• Decrease in stress response to surgery Decrease in stress response to surgery • Has sedative, anxiolytic and analgesic propertiesHas sedative, anxiolytic and analgesic properties• Reduce anesthetic requirement Reduce anesthetic requirement • Abrupt withdrawal can precipitate rebound Abrupt withdrawal can precipitate rebound

hypertensionhypertension• Should be continued in perioperative periodShould be continued in perioperative period• Transdermal clonidine for patients who may not be Transdermal clonidine for patients who may not be

able to resume oral medications by 12hrs after able to resume oral medications by 12hrs after surgerysurgery

Calcium Channel Calcium Channel BlockersBlockers

Limited data regarding benefits and risks of Limited data regarding benefits and risks of CCB CCB

Acute withdrawal symptoms not typical, Acute withdrawal symptoms not typical, though reported severe vasospasm in patients though reported severe vasospasm in patients undergoing revascularizationundergoing revascularization

No serious interactions with anesthetic agents No serious interactions with anesthetic agents Possible association with increased bleeding Possible association with increased bleeding

risk (Conflicting data)risk (Conflicting data) Can be safely administered in perioperative Can be safely administered in perioperative

periodperiod

ACE Inhibitors and ARBsACE Inhibitors and ARBs

ControversialControversial Can blunt the compensatory activation of Can blunt the compensatory activation of

the renin-angoiotensin system during the renin-angoiotensin system during surgery, leading to prolonged hypotensionsurgery, leading to prolonged hypotension

Possibly, reduces incidence of Possibly, reduces incidence of postoperative hypertensionpostoperative hypertension

Recommendations: continue ACEI/ARB in Recommendations: continue ACEI/ARB in patients with HTNpatients with HTN

Can withhold in pts with CHF, who also Can withhold in pts with CHF, who also have low BP have low BP

DiureticsDiuretics Possible adverse effectsPossible adverse effects HypokalemiaHypokalemia

• Can theoretically increase perioperative Can theoretically increase perioperative arrhythmia (not found in observational arrhythmia (not found in observational studies)studies)

• HypovolemiaHypovolemia• Anesthetic agents can induce vasodilatation, Anesthetic agents can induce vasodilatation,

leading to hypotension in pts who are leading to hypotension in pts who are volume depletedvolume depleted

• Most recommend withholding diuretics Most recommend withholding diuretics on the morning of surgery in some ptson the morning of surgery in some pts

Gastrointestinal AgentsGastrointestinal Agents

H2 blockers/PPIH2 blockers/PPI Decrease stress related mucosal Decrease stress related mucosal

damagedamage Decrease gastric volume and increase Decrease gastric volume and increase

gastric pHgastric pH Reduces risk of chemical pneumonitisReduces risk of chemical pneumonitis Should be continued in the Should be continued in the

perioperative periodperioperative period

Pulmonary agentsPulmonary agents

Inhaled beta agonists and anticholinergicsInhaled beta agonists and anticholinergics Reduces postoperative pulmonary Reduces postoperative pulmonary

complications in patients with COPD and complications in patients with COPD and asthmaasthma

Should be continued in perioperative periodShould be continued in perioperative period

TheophyllineTheophylline Potential for serious toxicityPotential for serious toxicity No data on benefitsNo data on benefits Recommendation: discontinue the evening Recommendation: discontinue the evening

before surgerybefore surgery

Pulmonary agentsPulmonary agents

CorticosteriodCorticosteriod Chronic use in COPD should continued in Chronic use in COPD should continued in

periopperiop Maintains optimal lung functionMaintains optimal lung function Minimizes risk of adrenal insufficiencyMinimizes risk of adrenal insufficiencyLeukotriene InhibitorsLeukotriene Inhibitors Effect on asthma symptoms and pulmonary Effect on asthma symptoms and pulmonary

function lasts up to 3 weeksfunction lasts up to 3 weeks No adverse interactions with anesthetic No adverse interactions with anesthetic

agentsagents Rec: continue in periopRec: continue in periop

Endocrine AgentsEndocrine AgentsInsulin and oral hypoglycemicsInsulin and oral hypoglycemics Generally can continue with subcutaneous insulin Generally can continue with subcutaneous insulin

perioperatively (rather than an insulin infusion) for perioperatively (rather than an insulin infusion) for procedures that are not long and complexprocedures that are not long and complex

Can switch patients taking long-acting insulin Can switch patients taking long-acting insulin (Ultralente or glargine) to an intermediate-acting (Ultralente or glargine) to an intermediate-acting insulin one to two days prior to surgery because of a insulin one to two days prior to surgery because of a potential increased risk for hypoglycemia potential increased risk for hypoglycemia

May also reduce the night time (supper or HS) May also reduce the night time (supper or HS) intermediate-acting insulin on the night prior to intermediate-acting insulin on the night prior to surgery to prevent hypoglycemia if the patient has surgery to prevent hypoglycemia if the patient has borderline hypoglycemia or tight control of the borderline hypoglycemia or tight control of the fasting blood glucose.fasting blood glucose.

Sliding scale may be used in place of oral Sliding scale may be used in place of oral hypoglycemics on morning of surgeryhypoglycemics on morning of surgery

Endocrine AgentsEndocrine Agents

HRT/SERMHRT/SERM Recommendation: Stop 4 -6 weeks Recommendation: Stop 4 -6 weeks

before surgery at moderate to high before surgery at moderate to high risk for thromboembolismrisk for thromboembolism

Can be continued in surgeries at low Can be continued in surgeries at low risk for thromboembolismrisk for thromboembolism

If on SERM for Breast Cancer – If on SERM for Breast Cancer – recommend consultation with recommend consultation with oncologistoncologist


Lipid Lowering agentsLipid Lowering agents May cause myopathy and May cause myopathy and

rhabdomyolysisrhabdomyolysis Statins may prevent vascular events Statins may prevent vascular events

and reduce perioperative mortalityand reduce perioperative mortality Recommendation: continue statins, Recommendation: continue statins,

discontinue niacin, fibric acid discontinue niacin, fibric acid derivative and cholestyramine at least derivative and cholestyramine at least one day before surgeryone day before surgery


Thyroid agentsThyroid agents Should be continuedShould be continued IV or IM administration if oral intake IV or IM administration if oral intake

cannot be resumed in 5 – 7 days cannot be resumed in 5 – 7 days after surgeryafter surgery

Medications that affect Medications that affect hemostasishemostasis

AspirinAspirin Optimal periop management uncertainOptimal periop management uncertain Inhibits platelet cyclooxygenaseInhibits platelet cyclooxygenase Increases intraop blood loss and hemorhagic complicationsIncreases intraop blood loss and hemorhagic complications May prevent vascular complications in cardiac surgeries May prevent vascular complications in cardiac surgeries

(CABG, PVD surgery)(CABG, PVD surgery) Recommendations: depends on pt risk factors and surgical Recommendations: depends on pt risk factors and surgical

procedureprocedure 2004 ACC/AHA: Continue CABG after ST elevation MI2004 ACC/AHA: Continue CABG after ST elevation MI Should be withheld in procedures with high hemorrhagic risk Should be withheld in procedures with high hemorrhagic risk

(CNS surgery)(CNS surgery) 5- 10 days before procedure (for new platelets to be formed)5- 10 days before procedure (for new platelets to be formed)Plavix, dipyridamolePlavix, dipyridamole Stop 7 – 10 days before surgeryStop 7 – 10 days before surgeryNSAIDSNSAIDS Stop 3 days before surgeryStop 3 days before surgery

WarfarinWarfarin Patients at low risk for perioperative bleeding, anticoagulation Patients at low risk for perioperative bleeding, anticoagulation

can be maintained at or below the low end of the therapeutic can be maintained at or below the low end of the therapeutic range (INR 2.0).range (INR 2.0).

Patients with a high risk of bleeding, INR should be 1.5. or less Patients with a high risk of bleeding, INR should be 1.5. or less Stop warfarin two to five days preop in those at low risk for thrombosisStop warfarin two to five days preop in those at low risk for thrombosis Stop warfarin in pts at high risk for thrombosis, but treat with intravenous Stop warfarin in pts at high risk for thrombosis, but treat with intravenous

or subcutaneous heparin when the INR is subtherapeutic.or subcutaneous heparin when the INR is subtherapeutic.

Can be restarted postop when there is no contraindication to Can be restarted postop when there is no contraindication to anticoagulation.anticoagulation.

Psychotropic AgentsPsychotropic Agents

TCATCA Withdrawal symptoms: insomnia, Withdrawal symptoms: insomnia,

headache, increased salivationheadache, increased salivation Recommend: ContinueRecommend: Continue SSRIsSSRIs May increase need for blood May increase need for blood

transfusionstransfusions Inhibits platelet aggregationInhibits platelet aggregation Recommend: Weigh benefits vs. risksRecommend: Weigh benefits vs. risks

Chronic Opioid TherapyChronic Opioid Therapy

Abrupt discontinuation may result in Abrupt discontinuation may result in withdrawal symptomswithdrawal symptoms

Continue in periop period Continue in periop period If oral intake not possible, consider If oral intake not possible, consider

alternative routesalternative routes Higher doses may be required Higher doses may be required

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Preoperative Assessment of Older Adults.ppt