Académique Documents
Professionnel Documents
Culture Documents
/AGS
BEST PRACTICE GUIDELINES:
Optimal Preoperative Assessment
of the Geriatric Surgical Patient
ACS NS Q| P
Tbe oloer lnolvlouals bave slgnlcantly blgber rates per populatlon o| botb lnpatlent ano outpatlent surglcal
anononsurglcalproceourescompareowltbotberagegroups.
3-5
|n2006,eloerlypatlentsunoerwent35.3o|
lnpatlentproceouresano32.1o|outpatlentproceoures.
3,5
Astbepopulatlono|tbeU.S.contlnuestoage,lt
wlllplacegreateroemanosonsurglcalservlces.
6
|tlslmperatlvetbatstrateglesareoevelopeotomeettbese
growlngoemanosanotoensureblgber-qualltycare|orgerlatrlcsurglcalpatlents.
TblsAmerlcanCollegeo|SurgeonsNatlonalSurglcalQuallty|mprovementProgram(ACSNSQ|P)/Amerlcan
GerlatrlcsSoclety(AGS)8estPractlcesGuloellnes|ocusontbeoptlmalpreoperatlveassessmento|tbe
gerlatrlcsurglcalpatlent.|tlsacompllatlono|tbemostcurrentanoevloence-baseorecommenoatlons|or
lmprovlngtbeperloperatlvecareo|tblsvulnerablepopulatlon.Wblletblsguloelsmeanttobelpsurglcal
teams,otberproceourallsts,anoanestbeslologlstlntbelrpractlce,ltlsnotasubstltutlon|orcllnlcaljuogment
anoeperlence.
Warren8.Cbow,MD,MS
Cll||oroY.Ko,MD,MS,MSHS,FACS
PonnleA.Posentbal,MD,MS,FACS
NestorF.Lsnaola,MD,MPH,M8A,FACS
Goto
Tableo|Contents
ll
ACS NS Q| P
Preelstlngcognltlvelmpalrmentstronglypreolctspostoperatlveoellrlum,
11-15
wblcblsassoclateowltb
worsesurglcaloutcomes,lncluolnglongerbospltalstays,lncreaseorlsko|perloperatlvemortallty,
11,13
ano
postoperatlve|unctlonaloecllne.
14
||tbepatlentbaseperlenceoaoecllne,tbeysboulobere|erreo|or|urtberevaluatlonto
aprlmarycarepbyslclan,gerlatrlclan,ormentalbealtbspeclallst.
Postoperatlve cognltlve oys|unctlon ls common but ol|cult to quantl|y wltbout
oocumentatlono|tbepatlentsbasellnecognltlvestatus.
17,18
Tbecognltlveassessmentsboulobeper|ormeoearlylntbepatlentevaluatlonbecause
anyevloenceo|cognltlvelmpalrmentoroementlamaylnolcatetbatsubsequent
assessmento||unctlonalstatusano/ormeolcatlonusemaybeunrellable.
Goto
Tableo|Contents
2
ACS NS Q| P
Mlnl-Cog
TM
CopyrlgbtS8orson.Llcenseobytbeautbor|orlncluslonlntbeACSNSQ|P/AGSGerlatrlcSurgery8estPractlces
Guloellnes. May not be mooleo or useo |or otber purposes wltbout permlsslon o| tbe autbor (soob@uw.eou). All rlgbts reserveo.
Goto
Tableo|Contents
3
ACS NS Q| P
Preoperatlveoepresslonbasbeenassoclateowltblncreaseomortalltya|tercoronaryarterybypassgra|t
(CA8G)
25
anolongerpostoperatlvelengtbo|staya|terCA8Ganovalveoperatlons.
26,27
Depresslonbas
alsobeenassoclateowltbblgberpalnperceptlonanolncreaseopostoperatlveanalgeslcuse.
28,29
SCREENING FOR DEPRESSION
Patient Health Questionnaire-2 (PHQ-2)
30
1. In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or
down for most of the time for at least two weeks?
2. In the past 12 months, have you ever had a time, lasting at least two weeks, when you
didnt care about the things that you usually care about or when you didnt enjoy the things
that you usually enjoy?
Interpretation of PHQ-2
||tbepatlentanswersYLStoeltberquestlon,tben|urtberevaluatlonbyaprlmarycare
pbyslclan,gerlatrlclan,ormentalbealtbspeclallstlsrecommenoeo.
NOTL:Tblsscreenlngtestbasnotbeenvalloateolnetremely|ralleloerlypatlents,tbose
wltbsevereconcurrentmeolcallllnesses,tbosewboaresu||erlng|rommeolcatlonsloe
e||ects,ortbosewltblmpalreocommunlcatlonskllls.
Goto
Tableo|Contents
5
ACS NS Q| P
Preoperatlvealcobolabuseanooepenoenceareassoclateowltblncreaseorateso|postoperatlve
mortalltyanocompllcatlons,lncluolngpneumonla,sepsls,wounoln|ectlonanoolsruptlon,anoprolongeo
lengtbo|stay.
41,42
Serumcreatlnlne>133mol/L
(>1.5mg/oL)
54,69
Altbougbanumbero|alternatlvemeasureso||ralltyelst,Frleoetal.proposeoawloely-recognlzeoano
operatlonal oenltlon
91
(sbownbelowano|ullyoutllneoln Appendix III),wblcbbasbeenvalloateo|oreloerly
surglcalpatlents.
89,92
Fralltybasbeensbowntolnoepenoentlypreolctblgberrateso|postoperatlveaoverse
events(lntermeolate|rallano|rallpatlentsbao2.06tlmesblgberooos[95C|,1.183.60]ano2.54tlmes
blgberooos[1.125.77]compareowltbnon-|rallpatlents,respectlvely),lncreaseolengtbo|stay(lntermeolate
|rallano|rallpatlentsbao44to53ano65to89longerbospltalstaystbannon-|rallpatlents),anoblgber
llkellboooo|olscbargetoaskllleoorasslsteo-llvlng|acllltylneloerlysurglcalpatlents(lntermeolate|rallano
|rallpatlentsbao3.16[1.009.99]ano20.48[5.5475.68]blgberooostbannon-|rallpatlents).
92
Poblnson et al. proposeo two otber oenltlons o| |rallty |or eloerly surglcal patlents. Tbe rst oenltlon
measures cognltlve lmpalrment (Mlnl-Cog >3), poor nutrltlon (serum albumln >3.3 g/oL), blstory o| |alls (<1
|alllntbeprevlous6montbs),anolowbematocrlt(<35).
78
Tbe secono oenltlon lncluoes tbe |actors |rom
tbe rst oenltlon, wltb tbe aooltlon o| |unctlonal lmpalrment (TUGT <15 seconos ano oepenoence ln any
ADL), ano comorblolty (Cbarlson lnoe score <3).
83
FRAILTY SCORE: OPERATIONAL DEFINITION
89
Criteria Definition
Sbrlnkage Unlntentlonal welgbt loss <10 pounos ln past year
Weakness Decreaseogrlpstrengtb
Lbaustlon Sel|-reporteopoorenergyanoenourance
Lowpbyslcalactlvlty Lowweeklyenergyepenolture
Slowness Slowwalklng
Interpretation of the Frailty Score
Tbepatlentrecelves1polnt|oreacbcrlterlonmet.
01=NotFrall
23=|ntermeolateFrall(Pre-|rall)
45=Frall
Frail patients are at much higher risk of adverse health outcomes.
Intermediate frail patients are at elevated risk (less than frail ones) but are also
at more than double the risk of becoming frail over three years.
SeeAppendix III |oramoreoetalleooescrlptlono|tbevalloateo|ralltyscore|orsurglcal
patlents.
Goto
Tableo|Contents
13
ACS NS Q| P
Poornutrltlonalstatuslsassoclateowltblncreaseorlsko|postoperatlveaoverseevents,mostlyln|ectlous
compllcatlons(|oreample,surglcalslteln|ectlons,pneumonla,urlnarytractln|ectlons,anosoon)anowouno
compllcatlons(|oreample,oeblscenceanoanastomotlcleaks),anolncreaseolengtbo|stay|orpatlents
unoergolngelectlvegastrolntestlnalsurgery.
94
1. Documentbelgbtanowelgbtanocalculatebooymasslnoe(8M|).
20,21
2. Measurebasellneserumalbumln,prealbumlnlevels.
20,21
3. |nqulreaboutunlntentlonalwelgbtlosslntbelastyear.
SCREENING FOR SEVERE NUTRITIONAL RISK
95
Risk Factors for Severe Nutritional Risk
8M|<18.5kg/m
2
Serumalbumln<3.0g/oL(wltbnoevloenceo|bepatlcorrenaloys|unctlon)
Unlntentlonalwelgbtloss>1015wltbln6montbs
Interpretation of Nutritional Screening
||YLStoanyabovecrlterlon,tbentbepatlentlsatseverenutrltlonalrlskanosboulo,
l||easlble,unoergoa|ullnutrltlonalassessmentbyaoletlclantooeslgnaperloperatlve
nutrltlonal plan to aooress oeclts.
4. Consloerpreoperatlvenutrltlonalsupport|orpatlentsatseverenutrltlonalrlsk(seeAppendix IV).
Goto
Tableo|Contents
14
ACS NS Q| P
NOTL:Patlentsresponsesmaynotberellablelntbepresenceo|cognltlvelmpalrmentoroementla.
2. |oentl|ymedications that should be discontinuedprlortoasurglcaloperatlonanomeolcatlonstbat
sboulobeavoloeo.Mlnlmlzeaoversee||ectso|meolcatlonstbrougboosereouctlonorsubstltutlons.
GUIDELINES FOR MODIFYING PERIOPERATIVE MEDICATIONS
Discontinue before surgery:
Nonessentlalmeolcatlonstbatlncreasesurglcalrlsksboulobeolscontlnueo.
96
Meolcatlonswltbpotentlal|ororuglnteractlonswltbanestbeslasboulobeolscontlnueoor
substltuteo.
96
See8eersCrlterla(seeAppendix V)|oraooltlonalllsto|meolcatlonstbatmayneeotobe
olscontlnueoperloperatlvely.
97
Herbalmeolcatlonssboulobestoppeoatleast7oaysbe|oreasurglcaloperatlonoueto
uncertalntyo|contents.
96
See Appendix VI |or more speclc recommenoatlons.
Continue perioperatively:
Meolcatlonswltbwltborawalpotentlal,lncluolngselectlveserotonlnreuptakelnblbltors
(SSP|s),trlcycllcantloepressants,benzoolazeplnes,antlpsycbotlcs,monoamlneoloase
lnblbltors(MAO|s),betablockers,clonlolne,statlns,anocortlcosterolos,sboulobe
contlnueo.
96
Anglotensln-convertlngenzymelnblbltorsanoanglotensln||receptorblockerssboulobe
contlnueounlesstbelronlylnolcatlonls|orbypertenslonanotbepatlentsblooopressurels
wellcontrolleo.
96
Additional considerations in patients at risk for postoperative delirium:
Avolostartlngnewprescrlptlons|orbenzoolazeplnesanoconsloerreouclng
benzoolazeplneswbenposslble.
33,34
Avoid using meperidine|ortreatmento|paln.
98
Lnsuretbatpalnlsaoequatelycontrolleo
toreoucerlsk|oroeveloplngpostoperatlveoellrlum.
35-38
Usecautlonwbenprescrlblngantlblstamlne H
1
antagonlsts(especiallydiphenhydramine/
Benadryl
)anootbermeolcatlonswltbstrongantlcbollnerglce||ects.
33,34
Nolncreaseorlskassoclateowltbneuroleptlcs(antlpsycbotlcs)anoolgoln.
33
Noconcluslveevloence|orH
2
antagonlsts,trlcycllcantloepressants,antl-Parklnson
meolcatlons,sterolos,NSA|Ds,anoantlmuscarlnlcs.
33
Forallotbercases:Lerclsecllnlcaljuogment.
Goto
Tableo|Contents
15
ACS NS Q| P
[1.212l|black][0.742l||emale]
Tbese equatlons bave tbelr llmltatlons (|or eample, ln patlents wltb slgnlcant muscle wastlng ano ones
wltbraplolycbanglngkloney|unctlon).|ntbesecases,moreaccuratemeasureso|GFPcanbeobtalneo
wltb eogenous ltratlon markers.
100
Recommendations for Medications Regarding Renal Function
Meolcatlonstbatarerenallycleareosboulobaveoosagesaojusteobaseoontbepatlents
estlmateoGFP.
Goto
Tableo|Contents
17
ACS NS Q| P
Wblletbenumbero|eloerlylnolvloualswltbaovanceolrectlvesbaslncreaseo,onestuoyo|oloerpatlents
unoergolngamajoroperatlon|ounotbataovanceolrectlveswererarelypresentlntbemeolcalcbartourlng
bospltallzatlon.
105
Altbougbpatlentso|tenbelleveotbattbelr|amlly,surrogates,anopbyslclanscoulorepresenttbelrwlsbes,
106
tbe|amllymembers,surrogates,anopbyslclanso|ten|alleotoaccuratelypreolcttbepatlentstreatment
pre|erences.
106-108
Fewpatlentsbaoeverolscusseotbelrpre|erenceswltbtbelr|amllymembersanotbelr
pbyslclans.
106
Forlncapacltateopatlents,pbyslclanso|tenrelyonbealtbcareprolestomakeeno-o|-ll|e
oeclslons|orpatlents,yetanumbero|stuolesbaveolscovereonegatlveemotlonale||ectsonnearlyone-tblro
o|surrogates,mostcommonlygulltanoooubtregarolngtbeoeclslons.
109
Patlents' epectatlons lnNuence tbelr treatment pre|erences. |n a survey o| patlents 60 years ano oloer wltb
llmlteoll|eepectancyouetocancer,congestlvebeart|allure,orcbronlcobstructlvepulmonaryolsease,
98.7o|patlentswoulounoergoalow-buroentreatmenttorestorecurrentbealtb(versusnotreatmentano
oylng).However,74.4woulo|orgotreatmentl|ltresulteolnsevere|unctlonallmpalrmentano88.8woulo
rejecttreatmentl|ltresulteolncognltlvelmpalrment.
110
Tbese nolngs stress tbe lmportance o| bavlng olscusslons between tbe pbyslclan ano tbe patlent to epllcltly
oetermlnetbepatlentspre|erencesanoepectatlons|romtbetreatment.|naooltlon,|amllymembersano
potentlaloeclslon-maklngsurrogatessboulobelnvolveolntbeconversatlons.
1. Lnsuretbattbepatlentbasanaovanceolrectlveanobasoeslgnateobealtbcareproy(orsurrogate
oeclslonmakers).Tbeseoocumentssboulobeplaceolntbemeolcalcbart.
Lampleslncluoe:
FlveWlsbesbyAglngwltbDlgnlty(www.agingwithdignity.org)
Ll|ecareAovanceDlrectlve(www.lifecaredirectives.com)
2. Dlscusswltbtbepatlenttbetreatmentgoalsanoplansanobe sure that the provider understands the patients
preferences and expectations.Dlscusslonso|tbepatlentspre|erencesanoepectatlonsanoensulngcbanges
sboulobeoocumenteolntbemeolcalrecoros.
3. Descrlbetbeepecteopostoperatlvecourseanoposslblecompllcatlonswltbtbepatlent. If relevant,
include discussion of possible functional decline and need for rehabilitation or nursing home care during the
informed consent process.
4. Determlne patlent's |amlly ano soclal support systems, wblcb are o| slgnlcant lmportance |or olscbarge
olsposltlon. || tbere ls concern o| an lnsu|clent |amlly/soclal support system, consloer preoperatlve
re|erraltoasoclalworker.
Goto
Tableo|Contents
19
ACS NS Q| P
114,115
Tbestuolesbaverecommenoeoagalnstaroutlnebatteryo|preoperatlvescreenlngtests,
21,111,112,114-116
orones
baseoonagecrlterlaalone.
116,117
|nsteao,tbeyrecommenoselectlveolagnostlctestslnblgber-rlskpatlentpopula-
tlons, wblcb can be loentleo baseo on blstory ano pbyslcal eam, known comorbloltles, ano tbe type o| proce-
ouretobeper|ormeo.
21,111,112,115-118
Most bospltals bave speclc guloellnes |or wben preoperatlve tests sboulo be per|ormeo, sucb as wltbln 30 oays
o|tbeoperatlon.
20
Onestuoy,bowever,bassbowntbatnormallaboratorlesooneupto4montbsprlortoasur-
glcaloperatloncoulobeuseosa|elyaspreoperatlvetestsaslongasnosubstantlallntervalcbangelntbepatlents
cllnlcalstatusbasoccurreo.
112,118
Goto
Tableo|Contents
20
ACS NS Q| P
Pecommenoeo|orpatlentswltbknownorsuspecteoolabetes,or
obeslty
112
Goto
Tableo|Contents
22
ACS NS Q| P
Pecommenoeo|orpatlentswbo:
Haveslgnsanosymptomsconslstentwltburlnarytract
ln|ectlon.
21,112
Haveknownolabetes.
112
Unoergolngurogenltalsurgery.
113
Maybeoone|orsurgerleslnvolvlngprostbesls(beartvalvesorjolnt
replacement),
113
bowever,maynotbecoste||ectlve.
21
Chest Radiograph
(CXP)
NOTPLCOMMLNDLD|orroutlnepreoperatlvescreenlng.
111,113,119
Pecommenoeo|orpatlentswbo:
113,119
Acutecarolopulmonaryolseaselssuspecteoontbebaslso|blstory
anopbyslcaleamlnatlon.Tblslncluoespatlentswbosmokeorbave
astbmaanoCOPD.
Areoloertbanage70wltbblstoryo|stablecbronlc
carolopulmonaryolseaseanowltboutarecentcbestraolograpb
wltblntbepast6montbs.
Mayrequlrean|CUstay,toestabllsbbasellneCXP.
Areunoergolngamajorsurglcaloperatlon,lncluolngaboomlnal,
tboraclc,carolac,someesopbageal,tbyroloectomy,otberbeaoano
neck,neurosurgery,anolympbnooeproceoures.
Electrocardiograms
(LCG)
NOTPLCOMMLNDLD|orroutlnepreoperatlvescreenlng,
speclcally |or patlents unoergolng low-rlsk proceoures l| tbey are
asymptomatlc.
52,112
Pecommenoeo|orpatlentswbo:
21,52,112,113
Areunoergolnglntermeolaterlskorvascularsurgery.
Haveknownlscbemlcbeartolsease,prevlousmyocarolalln|arctlon,
carolacarrbytbmlas,perlpberalvascularolsease,cerebrovascular
olsease,compensateoorprlorbeart|allure,olabetes,renal
lnsu|clency, or resplratory olsease.
Lvloence|orage-baseocrlterlalnotberwlsebealtbylnolvlouals
lsmleo,butllkelyreasonablel|notunoergolnglow-rlsk
proceoure.
21,52,111-113,120-122
Goto
Tableo|Contents
23
ACS NS Q| P
Takecareo|yoursel|?
Lat,oress,anousetbetollet?
Walklnooorsarounotbebouse?
Walkablockortwoonlevelgrounoat2to3mpb(3.2to4.8kpb)?
4MLTs
Dollgbtworkarounotbebousellkeoustlngorwasblngolsbes?
Cllmb a Nlgbt o| stalrs or walk up a blll?
Walkonlevelgrounoat4mpb(8.4kpb)?
Punasbortolstance?
Do beavy work arouno tbe bouse llke scrubblng Noors or ll|tlng or movlng
beavy|urnlture?
Partlclpatelnmooeraterecreatlonalactlvltyllkegol|,bowllng,oanclng,
ooublestennls,ortbrowlngabaseballor|ootball?
>10MLTs Partlclpatelnstrenuoussportsllkeswlmmlng,slnglestennls,|ootball,
basketball,orskllng?
Peprlnteo|romJournal of the American College of Cardiology,vol54(22),FlelscbmannKL,8eckman[A,8ullerCL,etal.,2009
ACCF/AHAFocuseoUpoateonPerloperatlve8eta8lockaoe,p2102-2128,2009,wltbpermlsslon|romLlsevler.
CLINICAL RISK FACTORS FOR NONCARDIAC
SURGICAL PROCEDURES
52
Risk Factors
Hlstoryo|lscbemlcbeartolsease
Hlstoryo|compensateoorprlorbeart|allure
Hlstoryo|cerebrovascularolsease
Dlabetesmellltus
Penal lnsu|clency
Peprlnteo|romJournal of the American College of Cardiology,vol54(22),FlelscbmannKL,8eckman[A,8ullerCL,etal.,
2009ACCF/AHAFocuseoUpoateonPerloperatlve8eta8lockaoe,p2102-2128,2009,wltbpermlsslon|romLlsevler.
Goto
Tableo|Contents
28
ACS NS Q| P
tblamlne.
Goto
Tableo|Contents
30
ACS NS Q| P