OLDER SURGICAL PATIENTS :

ANESTHESIOLOGIST’S POINT OF VIEW

ANNEMARIE CHRYSANTIA MELATI
Introduction

Aging population

Degenerative process on the

system structure and functional

Perioperative assessment should

be tailored for each geriatric
patients
 Increased number of elderly
population

Development of medical tech

Better health care access

Increased number of
older surgical patients
Total (>65 years) : 34%
Why are they so special?

Comorbid illness

Even if they are

perfectly healthy
the ability to handle
surgical stress will be
diminished

Silverstein JH, Rooke GA, Reves JG, McLeskey CH. Geriatric Anesthesiology. 2nd Ed. Springer, 2008.
Prospective cohort of 372 elderly patients

Mean recovery times :

MMSE - 3 weeks

ADL, SF-36 PCS and functional reach - 3 months

IADL - 6 months
 Control of Perioperative Pathophysiology

Patient Surgical Non-Opioid Physical Enteral

Information Stress Pain Relief Activity Nutrition

Postoperative Physical Capacity

Morbidity and Rehabilitation Needs

Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg; 2002: 183(6): 630-41.
 Control of Perioperative Pathophysiology

a ch
p ro
Patient Surgical
p
Non-Opioid
a
Physical Enteral

d
Information Stress Pain Relief Activity Nutrition

il s e
o n a
e rs Postoperative Physical Capacity
P
Morbidity and Rehabilitation Needs
Not all elderly are the same
Preoperative Assessment
Comprehensive and transdisciplinary

Patient information and explanation

Risk assessment

Optimization of medical and physical condition -

prehabilitation

Premedication as per indication

Transdisciplinary Care in Geriatric
Surgery
Patient = Home Owner
Surgeon = Architect
What do we need to build a house?
 p r o b l e m ?
h a t ’s t h e
W
 Pitfalls of Multidisciplinary Approach
Failure to share common vision of
final outcome

Failure of coordination

Failure of effective communication

Failure of members of the team to

understand what the other is doing

Failure of members of the team to

follow through from beginning till
finish
Transdisciplinary Geriatric Care
 Frailty
Increase vulnerability

Reduced physical activity

Genetic and environmental

factors

Associated with, but

remains distinct from,
increasing age

Patel KV, Brennan KL, Davis ML. Association of a modified frailty index with mortality after femoral neck fracture in patients aged
60 years and old. Clin Orthop Relat Res. 2014;472(3):1010-7.
Prehabilitation
Method of enhancing the
functional capacity of a patient

Preparation of surgical stress

Goals : to prevent
deconditioning and improve
the ability of the patient to
withstand the stressors of
surgery
Carli F, Bousquet-Dion G. Improving perioperative functional capacity : a case for prehabilitation. Geriatr Anesthesiol. 2017:73-84.
Temperature Control

Impaired thermoregulation
Wh
pat ile I
ient a mc
as s sho o
Anesthesia and surgical environment
col u o l ,
d a d no l
sI t
am be
Perioperative hypothermia persists …
longer

Associated with poor prognosis,

increased mortality, infection, increased
length of stay
- Prolonged hospital stay
- Increased surgical site infections
- Mortality
Postoperative Care

Multimodal analgesia (opioid-sparring)

Avoid fluid excess

Prevention of nausea and vomiting

Enhance recovery
Early nutrition
process
Early mobilization

Early removal of tubes/drains

 Multimodal Analgesia
Non-Opioid
Non-Pharmacologic
Therapies
+ Pharmacologic = GOAL
Therapies
Acupuncture Acetaminophen
Ice NSAIDs Reduced opioid
Manipulation or massage Local anesthetic use
Music therapy Anticonvulsants

Physical therapy Antidepressants
Muscle relaxants
Early Mobilization
Postoperative Delirium
✤ Most common form of periop
CNS dysfunction

✤ Acute confusion, decreased

alertness, misperception

✤ Twice as common in elderly

✤ Seen after GA/RA

✤ Prolonged hospital stay

How to Prevent POD?
✤ Minimize benzodiazepines, anticholinergic

✤ Maintained BP greater 2/3 baseline

✤ Maintained O2 sat >90%

✤ Maintained HCT >30%

✤ Mobilized patients soon

✤ Appropriate environmental stimulus

Conclusion

Surgical risk and planned

perioperative care should
be tailored for each geriatric
patients

Transdisciplinary approach
for the best outcome
“A patient’s age should be treated as a scientific fact, not with
prejudice. No particular chronologic age, of itself, is a
contraindication to operation.”

Principles of Geriatric Surgery

In : Rosenthal RA, Zenilman ME, Katlic MR, editors. Principles and practice of geriatric
surgery. New York (NY): Springer; 2001. Principles of geriatric surgery; pp. 92–104
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