Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective

Older veterans undergoing inpatient surgery: What is the compliance with best practice guidelines?

BACKGROUND

The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution.

METHODS

A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications.

RESULTS

The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care).

CONCLUSION

Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes.

Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study

INTRODUCTION

Geriatric patients have a pronounced risk to suffer from postoperative complications. While effective risk-specific perioperative measures have been studied in controlled experimental settings, they are rarely found in routine healthcare. This study aims (1) to implement a multicomponent preoperative and intraoperative intervention, and investigate its feasibility, and (2) exploratorily assess the effectiveness of the intervention in routine healthcare.

METHODS AND ANALYSIS

Feasibility and exploratory effectiveness of the intervention will be investigated in a monocentric, prospective, non-randomised, controlled trial. The intervention includes systematic information for patients and family about measures to prevent postoperative complications; preoperative screening for frailty, malnutrition, strength and mobility with nutrient supplementation and physical exercise (prehabilitation) as needed. Further components focus on potentially inadequate medication, patient blood-management and carbohydrate loading prior to surgery, retainment of orientation aids in the operating room and a geriatric anaesthesia concept. Data will successively be collected from control, implementation and intervention groups. Patients aged 65+ with impending surgery will be included. A sample size of 240, n=80 per group, is planned. Assessments will take place at inclusion and 2, 30 and 180 days after surgery. Mixed-methods analyses will be performed. Exploratory effectiveness will be assessed using mixed segmented regressions. The primary endpoint is functional status. Secondary endpoints include cognitive performance, health-related quality of life, length of inpatient stay and occurrence of postoperative complications. Feasibility will be assessed through semi-structured interviews with staff and patients and quantitative analyses of the data quality, focussing on practicability, acceptance, adoption and fidelity to protocol.

ETHICS AND DISSEMINATION

The study will be carried out in accordance with the Helsinki Declaration and to principles of good scientific practice. The Ethics Committee of the Medical Association Hamburg, Germany, approved the protocol (study ID: PV5596). Results will be disseminated in scientific journals and healthcare conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03325413.

Anesthetic management of geriatric patients

The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.

Bariatric surgery in older adults: Should there be an age limit?

Obesity has become one of the most significant health problems worldwide, affecting more than one-third of the global population. The elderly population is not immune to this proportional increase in obesity. To date, there is no cure for obesity, but surgery is the most effective treatment available today.We analyzed the results of bariatric surgery in elderly patients for a period of 3 years. Patients 65 years old and older were included in the study, 451 older adults were included. The mean age of the study group was 67.92 years old (min. 65, max. 84). The mean body mass index (BMI) was 40.32 Kg/m (min. 34 and max. 59). Sleeve gastrectomy (SG) was the most common procedures, and were conducted in 346 (76.72%) patients, gastric bypasses (GBPs) in 53 (11.75%) of which 33 were roux en y GBP (7.32%) and 20 mini GBPs (4.43%), gastric banding in 48 (10.64%), and duodenal switching in 4 (0.89%) cases.There were 40 (8.86%) patients with perioperative complications, 6 (1.33%) required re-operations, 12 (2.66) patients with operative complications were treated conservatively, 8 (1.77%) re-admission 5 of them with intrabdominal abscess, and 14 (3.10%) with co-morbidities complications. More than 76% of the patients had co-morbidities, 1 year after surgery the average remission of diseases was 34.74%, the improvement was49.67% and no changes in the co-morbidities was 15.59%. There were no deaths reported in this cohort.The mean excess body weight (EBW) loss among the patients was 70.76% (from 32% to 92%). No failure of weight loss (less than 25% of EBW loss) was observed after the first postoperative year.Bariatric surgery offers obese elderly patients an acceptable result, and it can be offered to improve the quality of life of these patients. A new consensus conference panel is needed to set appropriate recommendations regarding criteria that limit bariatric surgery in older adults.

Preoperative Management of the Geriatric Patient: Frailty and Cognitive Impairment Assessment

As the population ages, more geriatric patients will be presenting for surgical procedures. Preoperative evaluation seeks to assess patients for geriatric syndromes: frailty, sarcopenia, functional dependence, and malnutrition. Age-related changes in physiology increase risk for central nervous system, cardiovascular, pulmonary, renal, hepatic, and endocrine morbidity and mortality. Identification of various comorbidities allows for preoperative optimization and for opportunities for intervention including nutritional supplementation and prehabilitation, which may improve postoperative outcomes.

Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity

Age-related cardiovascular disease in older adults is more likely to occur in combination with other age-related diseases, with mounting interactive complexity as multiple morbidities accumulate. Although invasive cardiac procedures are frequently recommended for cardiovascular disease, their value is less certain in the context of age-related intricacies of care. Tools for risk assessment before invasive procedures are insensitive to risks corresponding to the unique challenges of older adults. Recognizing multimorbidity and other age-related risks provides opportunities to intervene and moderate dangers. By refocusing risk assessment in terms of patient-centered goals, the fundamental utility of invasive cardiac procedures may be reconsidered and alternative therapies prioritized.