1. PERIOPERATIVE CARE Topic Suggestions for Lecturer:
-1-hour to 1½-hour lecture
-Use GRS slides alone or to supplement your own teaching materials.
-Refer to GRS7 for further content about perioperative care and for case vignettes (questions 1, 20, 31, 108).
-Supplement with handouts, eg, tables and figures from GRS7.
-Refer audience to the complementary GRS chapter and slide set, “Hospital Care.”
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2. OBJECTIVES Know and understand:
How age-related physiologic changes influence perioperative care
Risk factors for cardiovascular, pulmonary, renal, and neurologic complications
Elements of perioperative management of selected medical problems
How to avoid iatrogenic complications
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3. TOPICS COVERED Overview of Operative Therapy for Older People
Preoperative Assessment and Management
Perioperative Management of Selected Medical Problems
Avoiding Iatrogenic Complications
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4. SURGERY IS A COMMON TREATMENT FOR OLDER PATIENTS
More than 55% of all surgeries are done in patients ≥65 years old
Advances in care have lowered surgical risks and shifted the risk-benefit ratio to favor surgery in increasingly older patients with more complex conditions
Many of the chronic conditions that increase in prevalence with advancing age, such as cataracts, arthritis, vascular occlusions, and cancers, are amenable to surgery.
Although older patients account for just over half of all surgical procedures, they suffer three quarters of the postoperative mortality and also the disproportionate majority of postoperative morbidity. For this reason, physicians are commonly asked to perform preoperative evaluations to reduce the risks of complications and death and to optimize patient outcomes.
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5. AGE-RELATED CHANGES INFLUENCE PERIOPERATIVE CARE
As a result of normal aging, multiple organ systems may have limited physiologic reserve
Examples:
Cardiac and vascular stiffening complicate fluid management
Decreased thermoregulation  increased risk of perioperative hypothermia
The resulting “homeostenosis” greatly increases the risk of iatrogenic events
Other examples of age-related changes that should be considered during perioperative care:
Altered body composition, diminished kidney function, and decreased liver blood flow and enzyme activity contribute to changes in the pharmacokinetics of drugs.
Stiffening of the thoracic cage and decrements in ciliary function contribute to decreases in pulmonary reserve and heightened risk of postoperative pneumonia.
By mechanisms that are not yet fully elucidated, changes in the brain that accompany aging make older individuals exquisitely susceptible to postoperative cognitive changes.
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6. PREOPERATIVE CARE SHOULD BE INDIVIDUALIZED
Not all organ systems age at the same rate, even within an individual
Most older people have one or more chronic conditions that influence perioperative care, either directly or through the drugs they use
Thus, older patients require thorough and individualized preoperative care, and often benefit from a multidisciplinary approach
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7. PREOPERATIVE ASSESSMENT: CARDIOVASCULAR SYSTEM
The risk of postoperative cardiac events is directly related to age
To calculate cardiac risk:
ASA classification
ACC/AHA guideline
update/periupdate_index.htm
The American Society of Anesthesiologists (ASA) classification of patient physical status relies heavily on clinical judgment and is not specific for cardiovascular morbidity and mortality. However, this system has been used by anesthesiologists for years and has consistently been shown to be useful in predicting postoperative outcomes.
The ASA classification appears in GRS7 as Table 13.1.
The American College of Cardiology and the American Heart Association (ACC/AHA) Guideline for Perioperative Cardiovascular Evaluation for Noncardiac Surgery is widely employed to help stratify risk and direct management. This algorithm takes into account clinical predictors, functional status, and surgical risk.
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8. PREOPERATIVE CARDIAC ASSESSMENT GUIDELINE
Urgency of surgery
Presence of active major cardiac risk factors
Type of surgery
Patient’s functional capacity
Presence of other clinical risk factors
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9. Intermediate-risk surgery***
Yes
Proceed to surgery
Emergency surgery? No
Any of the following major risk factors present? unstable angina, myocardial infarction 7–30 days ago, decompensated heart failure, severe aortic stenosis, symptomatic mitral stenosis, significant arrhythmia*
Cancel or postpone surgery; correct acute cardiac conditions
Yes No
Is procedure low risk, eg, ambulatory, cataract, endoscopic, breast, or superficial surgery?
Yes
Proceed to surgery No
Is patient able to do light housework, climb a flight of steps, walk up a hill, or run a short distance?
Yes
Proceed to surgery
No or unknown
Assess for clinical risk factors: history of ischemic heart disease, prior or compensated heart failure, history of cerebrovascular disease, diabetes mellitus, renal insufficiency
Assessing Cardiac Risk in Noncardiac Surgery
*High-grade AV block, Mobitz II AV block, third-degree AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with resting heart rate 100 beats per minute, newly recognized ventricular tachycardia
**Open aortic or other major vascular surgery, peripheral vascular surgery
***Intraperitoneal or intrathoracic surgery, carotid endarterectomy, endovascular abdominal aortic aneurysm repair, head and neck surgery, orthopedic surgery, prostate surgery
SOURCE: Data from Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2007;116(17):e418–e499.
≥3 risk factors
1 or 2 risk factors
0 risk factors
Proceed to surgery with perioperative β-blockade; consider stress testing if it will change management
High-risk surgery**
Intermediate-risk surgery***
Proceed to surgery
Strongly consider stress testing if it will change management; if not, proceed to surgery with perioperative β-blockade

10. PREOPERATIVE CARE: CARDIOVASCULAR SYSTEM
Older patients with known CAD or more than one risk factor for CAD may benefit from perioperative β-blockers titrated to HR of 60-80, particularly if they are undergoing vascular surgery or major surgery. If β-blockade is decided, it should be performed in the weeks prior to surgery rather than perioperatively.
Aspirin and statins have been beneficial in nonrandomized studies of high-risk patients
Choose DVT prophylaxis based upon DVT/PE risk and type of surgery
Prophylactic antibiotics are recommended for selected patients to prevent bacterial endocarditis
The trend has moved away from preoperative non-invasive cardiac testing.
See GRS7 Table 13.2, “Perioperative Medical Therapy to Reduce Cardiovascular Complications of Surgery.”
See Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2007;116(17):e418−e499.
See GRS7 Table 13.4 on DVT prophylaxis
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11. CESSATION OF ANTICOAGULATION BEFORE SURGERY IN OLDER ADULTS
Weigh protective benefit versus bleeding risk in patients already on anticoagulation
Do not withhold for cutaneous surgery, dental extractions, minor oral procedures, or cataract surgery
For other procedures, cessation of warfarin, with or without low-molecular-weight heparin bridge therapy, is based on patient’s risk of thromboembolism
See GRS7 Table 13.3, “Cessation of Anticoagulation Before Surgery in Older Adults” and Table 13.4, “Deep Venous Thrombosis/Pulmonary Embolism (DVT/PE) Prophylaxis in Older Surgical and Medical Inpatients.”
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12. PREOPERATIVE ASSESSMENT: RESPIRATORY SYSTEM
Risk factors for pulmonary complications:
Patient-related: age, COPD, ASA class II or greater, heart failure, ADL deficit, low albumin
Procedure-related: emergency surgery; prolonged surgery; AAA repair; neurosurgery; or thoracic, abdominal, head and neck, or vascular surgery
Postoperative pulmonary complications have been reported to prolong the hospital stay by 1 to 2 weeks in the elderly age group.
A recent investigation of >160,000 veterans undergoing noncardiac surgery established a clinical prediction model for postoperative pneumonia. Patients were assigned points based on the type of operation, age decile, functional status, and selected clinical conditions (weight loss, administration of general anesthesia, impaired sensorium, history of stroke, level of blood urea nitrogen, and transfusion of >4 units of blood). Individual points were summed to create a score, and the study sample could be divided into 5 risk classes accordingly.
Pneumonia rates were 0.2% for those with 0 to 15 risk points, 1.2% for those with 16 to 25 risk points, 4.0% for those with 26 to 40 risk points, 9.4% for those with 41 to 55 risk points, and 15.3% for those with more than 55 risk points. As an example, an 82-year-old woman (17 points) with some functional limitations (6 points) who was undergoing an open cholecystectomy (10 points) under general anesthesia (4 points) would have a score of 37 points and fall into the category of patients with 9.4% risk of postoperative pneumonia. This tool may be useful in guiding perioperative respiratory care.
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13. 2007 ACP GUIDELINE FOR RISK ASSESSMENT AND PERIOPERATIVE MANAGEMENT OF PULMONARY COMPLICATIONS
Appraise risk factors
Routine chest x-ray not recommended except for known cardiac or pulmonary disease
Spirometry reserved for patients with suspected COPD
Post-op lung expansion therapy recommended
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14. PREOPERATIVE ASSESSMENT: KIDNEY FUNCTION
Accurate estimation of GFR is important
Renal and glomerular blood flow decrease with age, and muscle mass declines, so serum creatinine may appear normal even when kidney function is not
Many drugs used perioperatively may require dosage adjustment if renal function is impaired
In all older surgical patients, it is important to monitor IV fluids carefully, due to the decreased ability of the kidneys to appropriately retain salt and maximally concentrate or dilute urine in response to intravascular volume.
Volume resuscitation in older surgical patients is best achieved with normal saline or blood (if appropriate), since half-normal saline or water are hypotonic and more readily diffuse to extravascular tissues.
Impaired preoperative kidney function increases the risk of postoperative kidney failure. The impaired reserve makes the aging kidney more susceptible to the effects of even transient reduction of cardiac output or brief exposure to nephrotoxic medications.
Glomerular filtration rate (GFR) can be most accurately estimated by using:
The Cockcroft-Gault equation (see the section on elimination in the GRS7 chapter and slide set “Pharmacotherapy”)
The equation that was developed based on data from the Modification of Diet in Renal Disease (MDRD) Study
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15. PREOPERATIVE ASSESSMENT: RISK OF DELIRIUM
Preoperative risk factors in noncardiac surgery:
Age ≥70 years
Cognitive impairment
Limited physical function
History of alcohol abuse
Abnormal serum sodium, potassium, or glucose
Intrathoracic surgery or abdominal aneurysm surgery
The most important intraoperative risk factor for delirium is blood loss
Delirium is a common and morbid event in the postoperative period. The type of surgery appears to be an important determinant of delirium, with incidence rates ranging from about 4% or 5% in cataract or urologic procedures to as high as 50% or 60% in some series of patients with infrarenal abdominal aortic aneurysm repair or hip fracture surgery.
Patients with a post-operative hematocrit < 30% have an increased risk of delirium irrespective of the presence or absence of preoperative risk factors.
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16. AVOIDING IATROGENIC COMPLICATIONS
Encourage time out of bed and avoid restraints, to maintain mobility and function
Remove indwelling catheters as soon as possible, to reduce the risk of infection and the effects of restricted mobility
Stop IV fluids, and lift restrictions on diet, as soon as possible
Review medications regularly
Preserving mobility also reduces the risks of skin breakdown, muscle atrophy, joint stiffness, and bone loss.
Restricted diets and lack of access to water can contribute to compromise in nutrition and hydration. Continued administration of IV fluids after the patient is able to maintain hydration orally can result in volume overload and impaired oxygenation.
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17. POSTOPERATIVE CARE: HYPERTENSION
Search for a non-cardiovascular cause, such as pain or urinary retention
Assess volume status, review fluid administration, and note whether antihypertensives were omitted
Consider a parenteral antihypertensive for treating uncontrolled essential hypertension
Topical agents, such as topical nitroglycerin, may also be useful postoperatively if patient is unable to take oral medications
Parenteral forms of several classes of antihypertensives are available, including β-blockers, calcium-channel blockers, ACE inhibitors, and drugs that block both α- and β-adrenergic receptors.
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18. POSTOPERATIVE CARE: ARRHYTHMIA
Supraventricular tachycardia: Attempt to restore sinus rhythm, or at least control the ventricular rate, by infusing adenosine, a β-blocker, or a calcium-channel blocker
Atrial fibrillation:
Attempt conversion to sinus rhythm with electrical cardioversion or infusion of amiodarone if poorly tolerated
Spontaneous reversion to sinus rhythm often occurs within 6 weeks after surgery
Persistent a-fib (beyond 24–48 hours) increases the risk of thromboembolism, so consider anticoagulation
Cardiac rhythm disturbances are concerning because they can lead to myocardial ischemia and heart failure. Supraventricular tachycardia, commonly seen in older people, is associated with a history of prior supraventricular dysrhythmias, asthma, heart failure, and premature atrial complexes on a preoperative electrocardiogram. This rhythm disturbance is also more common in patients who have had vascular, abdominal, or thoracic procedures.
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19. POSTOPERATIVE CARE: HEART FAILURE
May develop as a result of excessive fluid administration, new cardiac ischemia, or arrhythmia
It can be extremely challenging to ensure optimal ventricular filling pressures by basing the assessment of volume status on physical examination and standard laboratory parameters alone
Pulmonary artery catheters have been recommended for high-risk patients, but studies have not shown a mortality benefit
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20. POSTOPERATIVE CARE: RESPIRATORY SYSTEM
Measures that may reduce the risk of postoperative pulmonary complications:
Encouragement of coughing
Deep breathing exercises
Incentive spirometry
Early mobility
Perioperative use of pulmonary function tests in patients with known lung disease is largely discouraged, but it may be useful in evaluating dyspnea or wheezing when the diagnosis is unknown.
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21. POSTOPERATIVE CARE: KIDNEY DAMAGE (1 of 2)
Early signs of postoperative kidney damage: oliguria, isosthenuria, increase in serum creatinine
Mechanisms of postoperative kidney damage:
Impaired renal blood flow: signaled by urine sodium <40 mEq/L, ratio of urine to plasma creatinine >10:1
Acute tubular necrosis: signaled by urine sodium >40 mEq/L, ratio of urine to plasma creatinine <10:1; urine sediment may have granular or epithelial cell casts
Obstructive nephropathy, especially in men with prostatic hyperplasia: bladder typically distended, palpable
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22. POSTOPERATIVE CARE: KIDNEY DAMAGE (2 of 2)
Acute tubular necrosis: Hold all potentially nephrotoxic medications and meticulously maintain a euvolemic state
Obstructive nephropathy: Insert a bladder catheter to reduce the risk of hydronephrosis and impaired kidney function
Indications for dialysis are no different in the perioperative period and include hypervolemia, hyperkalemia, metabolic acidosis, or encephalopathy
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23. POSTOPERATIVE CARE: GASTROINTESTINAL CONCERNS
Constipation
Order a laxative and a stool softener when a narcotic medication is ordered
Consider suggesting prunes, prune juice, applesauce, or bran
Diarrhea
Check manually for fecal impaction, and consider having stool specimen checked for leukocytes or Clostridium difficile
Focus carefully on volume resuscitation and treating the underlying cause
Constipation is quite common postoperatively, as a consequence of the combined effects of altered diet, immobility, and medication use. At times, ileus and obstipation may be severe and produce significant anorexia, nausea, and even vomiting. The role of postoperative iron therapy to treat anemia is unproven and probably also contributes.
See GRS7 Table 49.3, “Medications That May Relieve Constipation” (page 450).
Nausea is also common in the postoperative period, often as a result of narcotic, anesthetic, and other medications or slowed gut motility. See the section on nausea in the GRS7 chapter “Palliative Care” and the accompanying slide set.
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24. PERIOPERATIVE CARE: TYPE 2 DIABETES MELLITUS (1 of 2)
Oral drugs are usually held the day of surgery, especially metformin, which increases the risk of metabolic acidosis during times of stress
An option for optimizing glucose control:
Administer an IV glucose-containing solution at a constant rate while closely monitoring blood glucose by fingerstick assay
Administer SC insulin as needed to control glucose until the patient can resume eating
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25. PERIOPERATIVE CARE: TYPE 2 DIABETES MELLITUS (2 of 2)
Insulin-using patients with type 2 diabetes:
Day of surgery: Hold the outpatient dose of insulin and give “sliding-scale” insulin as needed
First day of eating by mouth: A general rule is to give half the outpatient dose of diabetes drugs, with sliding- scale insulin as needed
When patient can consume a usual diet: Resume full doses of diabetes drugs
Perioperative hyperglycemia among diabetic and nondiabetic patients is associated with morbidity and mortality in medical and surgical intensive-care- unit (ICU) patients and in patients undergoing coronary artery bypass grafting or carotid endarterectomy.
Maintaining glucose concentrations of <150 mg/dL with intravenous insulin in the perioperative period for patients undergoing vascular or major noncardiac surgery with planned ICU admission has reduced morbidity and mortality. However, maintaining tight glycemic control (≤110 mg/dL) among ICU patients has been associated with increased hypoglycemia and no reduction in mortality, so moderate glucose control in these patients is advised. The value of strict glycemic control in other surgical or medical inpatient populations has not been demonstrated.
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26. PERIOPERATIVE CARE: PATIENTS USING CORTICOSTEROIDS
Perioperative administration of “stress doses” of steroids is appropriate for:
Patients on prednisone >20 mg/day for >1 week
Patients with known adrenal insufficiency
If HPA axis function is in question:
Measure cortisol
Cortisol not elevated: Consider 30-minute ACTH test
HPA = hypothalamic-pituitary-adrenal; ACTH = adrenocorticotropic hormone.
Some authorities advise:
Minor procedure: The equivalent of 25 mg/day IV hydrocortisone the day of surgery only
Moderate surgical stress: The equivalent of 50 to 75 mg/day IV hydrocortisone (eg, IV hydrocortisone 20 mg every 8 hours) for 1 to 2 days
High surgical stress: The equivalent of 100 to 150 mg/day IV hydrocortisone (eg, IV hydrocortisone 50 mg every 8 hours, beginning within 2 hours of surgery) for 2 to 3 days, then transition to the usual steroid regimen
Other authorities simply recommend:
Elective, uncomplicated surgeries: Continue the outpatient dose of steroids.
Higher-risk operations or those anticipated to be complicated: Double or triple the outpatient dose by giving IV hydrocortisone up to 100 to 150 mg/day.
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27. PERIOPERATIVE CARE: REDUCING RISK OF DELIRIUM
When preoperative risk factors are present, clinicians should be especially vigilant about:
Correcting fluid, electrolyte, metabolic derangements
Optimizing replacement of blood loss
Encouraging mobility, avoiding restraints
Maintaining circadian rhythms
Enhancing sensory input
Prescribing medications cautiously
In a randomized study, a multicomponent intervention focusing on reducing sleep interruptions, minimizing medications and immobility, enhancing sensory input, and reducing dehydration reduced the incidence of delirium by one third over standard care for hospitalized medical patients.
This approach is likely to be beneficial for surgical patients as well. For the postoperative geriatric surgical patient, undertreated pain, constipation, electrolyte abnormalities, and perioperative MI must be particularly considered.
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28. POSTOPERATIVE CARE: COGNITIVE DECLINE
A syndrome distinct from delirium, characterized by abnormalities in learning and memory
Most common after cardiac surgery
Persists for many months in 10%–30% of patients
No demonstrated link to hypotension, hypoxemia, or type of anesthesia
Treatment is supportive
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29. POSTOPERATIVE CARE: PAIN (1 of 2)
The oldest-old and cognitively impaired patients are at highest risk for undertreatment of pain
Most postsurgical pain requires narcotic analgesia
For cognitively intact patients, consider a patient-controlled analgesia (PCA) pump to improve pain relief and lower use of narcotics
The evaluation and management of acute pain is similar to that of persistent pain; see the GSR7 chapter “Persistent Pain.”
Narcotic analgesics may precipitate constipation; thus, concomitant use of laxatives and stool softeners is generally advised.
See the Web site for Geriatrics At Your Fingertips for comprehensive, up-to- date information on pain medications and dosing:
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30. POSTOPERATIVE CARE: PAIN (2 of 2)
Less severe pain: Patient may tolerate acetaminophen (≤4 g/day) with narcotic analgesic as needed, if able to request pain relief
Patient unable to communicate effectively: Standing orders for narcotic analgesic, with frequent assessment of medication effect
Useful adjuncts: ice packs, heating pads, massage, relaxation techniques
Avoid NSAIDS
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31. SUMMARY
Surgery is an important therapeutic option for many older people
Preoperative assessment should be individualized, comprehensive, and, often, multidisciplinary
Attentive perioperative management minimizes complications in older patients, especially those with chronic medical problems and functional impairments
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32. CASE 1 (1 of 4)
A 72-year-old woman comes to the office for evaluation before left total-knee replacement.
Despite the worsening pain in her left knee, she remains active; she gardens and plays golf 4 days a week.
She has no known allergies and has never smoked.
Both her parents lived into their nineties.
Her history includes mild hypertension, for which she takes atenolol 25 mg/day.
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33. CASE 1 (2 of 4)
On physical examination, blood pressure is 121/82 mmHg and resting heart rate is 70 beats per minute.
Serum chemistries and CBC are within normal limits.
ECG shows no conduction delays and no ischemic changes.
Other than osteoarthritic changes in both knees, left worse than right, her examination is unremarkable.
Slide 33
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Slide 33

34. CASE 1 (3 of 4)
Which of the following is most appropriate for perioperative management of this patient?
Increase atenolol dosage to 50 mg/d; continue perioperatively.
Discontinue atenolol immediately before surgery; restart 48 hours after surgery.
Continue atenolol at the current dosage.
Discontinue atenolol; begin an ACE inhibitor plus a statin.
Slide 34
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Slide 34

35. CASE 1 (4 of 4)
Which of the following is most appropriate for perioperative management of this patient?
Increase atenolol dosage to 50 mg/d; continue perioperatively.
Discontinue atenolol immediately before surgery; restart 48 hours after surgery.
Continue atenolol at the current dosage.
Discontinue atenolol; begin an ACE inhibitor plus a statin.
ANSWER: C
This patient has a Revised Cardiac Risk Index of 0 (normal creatinine level; no heart failure, ischemic heart disease, or diabetes; and no history of cerebrovascular disease). For patients at low cardiac risk (index of 0 or 1) who are already on a β-blocker for hypertension, angina, arrhythmias, or other cardiac problems, β-blocker treatment should be continued perioperatively.
Perioperative β-blockers should not be started in patients at low cardiac risk (index of 0 or 1) who do not already take a β-blocker. In these patients, β- blockers offer no benefit and may be harmful. The available evidence suggests that benefit from β-blockers is primarily limited to patients with a Revised Cardiac Risk Index >2 who are undergoing major noncardiac surgery.
Increasing the dosage of β-blocker in a low-risk patient affords no benefit and may precipitate perioperative hypotension or bradycardia. Abrupt discontinuation of the β-blocker could result in rebound hypertension and tachycardia. In this patient, there is no indication for starting an ACE inhibitor.
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36. CASE 2 (1 of 4)
An 80-year-old man is brought to the ER because his cognition is rapidly deteriorating, his temperature is 39.4°C (103oF), and he has upper abdominal pain.
His family reports that he has steroid-dependent COPD.
He smokes one-half pack of cigarettes daily.
He has not been eating well and has lost 4.5 kg (10 lb) over the last 4 months.
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37. CASE 2 (2 of 4)
The patient uses a walker to ambulate short distances within the house and is dependent on his family for all IADLs.
Surgical evaluation and ultrasound study are highly suggestive of cholecystitis and possible abscess.
Admission laboratory data show a WBC count of 19 × 103/mm3 and a BUN of 32 mg/dL.
He is vigorously rehydrated before undergoing emergent cholecystectomy under general anesthesia.
Slide 37
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Slide 37

38. CASE 2 (3 of 4)
Which of the following is most likely to reduce the patient’s risk of postoperative pulmonary complications?
Incentive spirometry
Total parenteral hyperalimentation
Postoperative epidural analgesia
Routine nasogastric decompression
Slide 38
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Slide 38

39. CASE 2 (4 of 4)
Which of the following is most likely to reduce the patient’s risk of postoperative pulmonary complications?
Incentive spirometry
Total parenteral hyperalimentation
Postoperative epidural analgesia
Routine nasogastric decompression
ANSWER: A
Risk factors for postoperative pneumonia include type of surgery (AAA repair and thoracic and upper abdominal surgery carry the greatest risk), older age, diminished functional status, weight loss >10% over the previous 6 months, history of COPD, use of general anesthesia, impaired sensorium, history of stroke, increased BUN, transfusion of >4 units of packed RBCs, emergent surgery, smoking, chronic steroid use, and consumption of >2 drinks containing alcohol daily. Risk reduction can be maximized by discontinuing smoking at least 6–8 weeks before surgery, not an option for patients requiring emergency intervention.
This patient is at extremely high risk of postoperative pulmonary complications because of multiple risk factors. Aggressive interventions should be in place to minimize risk. Lung expansion therapy (such as incentive spirometry, continuous positive airway pressure, and deep breathing exercises) helps prevent decreased lung volumes and atelectasis associated with surgery and bed rest.
Nutrition support, including total parenteral nutrition in a patient unable to eat, is crucial to long-term management but provides no advantage in an acute situation.
Epidural analgesia does not appear to be more effective than patient-controlled intravenous analgesia in preventing postoperative pneumonia. Intraoperative use of shorter-acting neuromuscular-blocking drugs may be superior to general anesthesia alone in minimizing postoperative pulmonary complications.
Routine nasogastric decompression until bowel function returns does not reduce the risk of postoperative pneumonia. Nasogastric decompression after surgery should be reserved for patients who have nausea, vomiting, or symptomatic abdominal distention, or for patients who cannot tolerate oral intake.
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40. CASE 3 (1 of 4)
A 76-year-old woman comes from a rehabilitation facility to the hospital after she falls and fractures her right hip.
She was recovering from a recent hospitalization for pneumonia and exacerbation of COPD that left her profoundly deconditioned.
She uses a combined steroid and long-acting β-agonist inhaler and takes oral steroids for exacerbations. She is not oxygen-dependent.
She has no history of dementia but believes she has been more forgetful over the past year.
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41. CASE 3 (2 of 4)
The patient is vigorously hydrated, her pain is controlled with narcotics, and surgery is planned for the next morning under general anesthesia.
Slide 41
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Slide 41

42. CASE 3 (3 of 4)
Which of the following would be most likely to reduce the risk of postoperative delirium?
Start low-dose intravenous haloperidol and continue for 48 hours after surgery.
Start oral donepezil and continue indefinitely.
Obtain preoperative consultation with a geriatrician for a multifactorial risk-reduction strategy.
Provide stress doses of intravenous steroids perioperatively.
Avoid opioid analgesia after surgery.
Slide 42
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Slide 42

43. CASE 3 (4 of 4)
Which of the following would be most likely to reduce the risk of postoperative delirium?
Start low-dose intravenous haloperidol and continue for 48 hours after surgery.
Start oral donepezil and continue indefinitely.
Obtain preoperative consultation with a geriatrician for a multifactorial risk-reduction strategy.
Provide stress doses of intravenous steroids perioperatively.
Avoid opioid analgesia after surgery.
ANSWER: C
The prevalence of delirium in older hospitalized adults is as high as 60%. In- hospital development of delirium is associated with increased mortality, functional decline, longer stay, and discharge to a long-term–care facility.
Risk factors for development of in-hospital delirium are older age, chronic cognitive impairment, immobility, sleep deprivation, compromised hearing or vision, dehydration or volume overload, malnutrition, polypharmacy, bladder catheterization, anemia, pain, electrolyte disturbances, hypoxemia, and infection. Proactive geriatrics consultation to address common risk factors reduced the occurrence of delirium by one third in patients undergoing hip surgery.
The use of prophylactic haloperidol does not prevent delirium but can decrease the severity of the delirium and reduce the length of stay. However, in some studies, use of antipsychotics in patients with dementia has resulted in increased mortality. Until there is further data about the safety of antipsychotics in patients with delirium, they should be used cautiously.
The use of prophylactic noncompetitive cholinesterase inhibitors, such as donepezil, offers no benefit over placebo.
Stress doses of intravenous steroids may have been necessary if this patient had used systemic steroids chronically before surgery. Because this patient uses oral steroids only for exacerbations, stress doses may add to the patient’s confusion through adverse events affecting the central .
Withholding analgesics would not decrease the risk of delirium. In fact, poorly controlled pain is a risk factor for delirium.
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44. Copyright © 2010 American Geriatrics Society
ACKNOWLEDGMENTS
Editor: Annie Medina-Walpole, MD
GRS7 Chapter Authors: Colleen Christmas, MD
James T. Pacala, MD, MS
GRS7 Question Writer: Michael C. Lindberg, MD
Pharmacotherapy Editor: Judith L. Beizer, PharmD
Medical Writers: Beverly A. Caley
Faith Reidenbach
Managing Editor: Andrea N. Sherman, MS
Copyright © 2010 American Geriatrics Society
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