Transcript Surgical Care of Geriatric Patients

Peri-operative Care of
Gynecological
Geriatric Patients
R. Keith Huffaker, MD, MBA, FACOG
Disclosures
• None
References/Sources
•
Known concerns
• UpToDate (Falcone)
• FPMRS review course (Ridgeway)
• Obstetrics & Gynecology
•
My input
Overview
•
In past 100 years, life expectancy increased approximately 30 years
• Women spend 1/3 of lives in postmenopausal state
• Persistent slow reduction of physical abilities
•
Number of women over 65yo
• Increase from 32mil to 40 mil from 1990 to 2010
• Will increase to 75mil in 2050
•
75yo can expect to live 12 more years
• Functional
• Independent
• Decisions to operate
• Biologic age, not chronologic age
• Health status
• Loss of
•
•
•
•
•
•
•
•
Bone
Muscle
Cardiopulmonary reserve
Sensory acuity
Connective tissue integrity
Renal function
Nerve conduction speed
Etc.
• Increasingly susceptible to disease/complications as
immune function declines
• GI function often slows
• H. pylori common
• Sensitive to NSAIDs
• Insulin resistance increases
General Consequences of
Physiologic Decline
•
Vulnerable to acute stress
•
More chronic diseases
• DM
• Cardiac
• Pulmonary
•
Evaluation of organ function
• Renal readily done
• Others more challenging
• Heart
• Lung
• Cognitive
•
Bottom line is surgical risk increases
• Medicare database of over 66,000 women over 65yo
underwent surgery for urinary incontinence
• 30 day mortality 0.33%
• MI, PE, CVA, DVT, Pneumonia each 1%
• Sultana, et al. Am J of Obstet Gynecol 1997; 176:344.
• Comparison of 120 women over 79yo v. 1497 women 5079
• Older age: longer mean stay
• More UTIs, sepsis, psychiatric events, respiratory problems
• No significant differences in death, cardiovascular events,
thrombosis or wound infections
• Friedman, et al. Am. J of Obstet Gynecol 2006; 195:547.
• What are the four most common geriatric post-op
complications?
• A. Falls, delirium, surgery infections, electrolyte
imbalances
• B. CVA, MI, PE, DVT
• C. Pulmonary edema, CHF, DVT, CVA
• D. Surgery infections, PE, CVA, DVT
Four Common Geriatric
Postop Complications
• Answer: A
• Falls
• 30% of community dwelling >65y each yr
• Fractures, morbidity, mortality, cannot get up
• Delirium
•
•
•
•
17% of gyn-onc surgical pts
Mortality
Longer hospital stays
NH/SNF placement
• Surgery infections
• Impaired ADLs
• Decrease immune function
• Electrolyte imbalance
• Age
• Renal function
• Fluid mgt—periop
Preparing for surgery
• Is the patient a surgical candidate?
• Look at her
• Initial assessment
• Probe deeper
• Other opinions
• PCP
• Cardiology
• Etc.
• Manage patient expectations
• Be very clear regarding goals of surgery
• Vaginal surgery, obliterative procedures
• Sexual activity discussion—open and frank
• Most and probably all of my surgeries are intended
to improve quality of life
• Conservative options (pessaries)
• Delay surgery until patient is medically optimized
General Pre-operative
Evaluation
• H&P
• Anesthesia pre-op requirements
• Labs
• Often arbitrary
• CBC
• BMP
• Optimize general medical condition prior to surgery
• CXR
•
•
•
•
Certainly for pts >= 60yo
I use 50yo
Cardiac disease
Lung disease
• ECG
• May need additional evaluation
• Determined by PCP or cardiologist
• Smoking cessation 8wk or more before surgery
Communication
• Decreased hearing
• Slowed mental processing
• Include friends/family
• Use written or print materials
• Plain language—8th grade
• Allow questions from patient/family
• Confirm patient/family understanding
• Informed consent
• Limit postoperative misunderstandings
• Include family/friends
• Ask patient to state her understanding of plan
• Risks/potential complications
• “Indicated procedures” for unexpected findings
• Document discussions
Ambulation Concerns
• May need OT or PT involvement
• Preop
• Postop
• Floor nursing affected
• May need help with turning
• Can affect respiration which can affect choice of
anesthesia
• Decreased ambulation affects
•
•
•
•
•
•
Skin care
Wound care
Bladder function
Bowel function
Respiratory function
Cardiovascular function
Ambulation Test
• Timed get up and go
• Get up from chair w/o using arms
• Walk ten feet, turn
• Walk back and sit down
• >12 sec consider referring for additional mobility
testing
Major Medical Problems
• Heart disease
• Cancer
• Stroke
• Chronic lower respiratory disease
• Alzheimer’s/other dementia
• Clotting disorders
• Diabetes
• Renal disease
The leading cause of death for
women 65y and older is:
• A. CVA
• B. Cancer
• C. Cardiovascular disease
• D. CHF
Cardiovascular Disease
• Answer: C
• Leading cause of death for women 65yr and older
• Decreased arterial compliance
• Increased SBP
• Left ventricular hypertrophy
• Decreased cardiac output and HR response to stress
Cardiovascular Consequences
• Prone to hypotension
• Sensitive to increased HR, volume depletion
• Syncope, etc.
• Decreased CO and HR meaning stress response is
dampened and CHF more likely
• Impaired BP response to standing, volume
depletion, possible heart block
• Predictors of adverse periop cardiac events
•
•
•
•
•
•
Ischemic heart disease
CHF
CVD
IDDM
Serum Cr > 2.0mg/dL
Age
The second leading cause of death
for women 65y and older is:
• A. CVA
• B. All forms of cancer combined
• C. PE
• D. Accidents
Cancer
• Answer: B
• Second leading cause of death
• Must have increased awareness as provider—pre/intra/post-op
•
•
•
•
•
•
Vulvar
Ovarian
Endometrial
Vaginal
Bladder
Other
• Always review pathology reports and inform patients
The third leading cause of death for
women 65y and older is:
• A. Accidents
• B. Renal failure
• C. Respiratory – all causes
• D. CVA / Stroke
• E. I don’t care; I just want this to end.
Stroke
• Answer: sorry, not E; D
• Cerebrovascular disease is #3 cause of death
• Past history = increased risk (recent case)
• Family history
• Mgt of HTN (<120/<80) is key
• Be aware of anticoagulant/antiplatelet therapies
• When in doubt, involve PCP/Cards/Heme
• For me, always involve the above
Chronic Lung Disease
• At risk for ventilation problems and post-op
infections
• Must have pre-op anesthesia evaluation
• Increased intra-abdominal pressure
• Stress on pelvic floor surgery
• Wound problems—dehiscence
Dementia
• To operate or not?
• Relate Alzheimer’s surgical patient of mine
• Ambulation issue
• Must involve other care-givers, family, social services, etc.
• Affects bladder function, bowel function, etc.
• Also keep in mind different but similar: Sundowners affect
where patients get confused being in different setting
• ex. Pt anxious/confused/hostile in recovery room or floor room
after surgery.
• Treatment is get her back to normal surroundings.
Clotting disorders
•
Obvious concerns
• Post-op DVT +/- PE
• Intra-op bleeding on anti-coagulant therapies
•
Coumadin, lovenox, heparin, aspirin, Plavix, Predaxa, bridging therapies, etc.
• Must stop coumadin and bridge with Lovenox or heparin
• Stop Plavix 5 days before surgery
• Labs: PT, PTT, INR (1.0), plavix test, etc.
•
I always involve the prescribing doctor and usually hospitalists.
•
•
•
•
Hematology
Vascular
Internal Medicine
Prescribing doctor
•
•
Pre- and intra-op plan
Post-op plan
Diabetes
• Typically type 2/non-insulin-dependent in this age group
• Increased risk of comorbidities
•
•
•
•
Heart
Kidney
Neuropathy (also bladder function)
Vision
• Wound/healing complications
• Need reasonable control before going to surgery
Renal Disease
• Creatinine for chronic function evaluation
• BUN for more acute function evaluation
• Check for patient’s sake
• Check for doctor’s sake
• If any question of ureteral injury, pre-op labs might
prove/suggest diminished pre-op function
• Concern over pre-op ureteral function: perform
cystoscopy at start of case or in office to check for
ureteral efflux
Anemia
• My biggest concern is can a patient tolerate blood
loss
• Is she anemic pre-op?
• Can her heart tolerate blood loss? Fluid replacement?
Blood products?
• Should surgery be delayed to address anemia?
• Typically anemia in older patients will not be
surgical emergency (for instance, does not need
D&C acutely)
Anemia and IVFs
• Be careful with volume replacement
• Go slow
• I prefer lower rates of infusion such as 75 or 100ml if
patient is stable and over 65yo.
• Be aware of cardiac function/history
• Give only small volume if bolus needed
• Be aware of whether patient typically takes
HCTZ/Lasix/Spironolactone and whether she took it
peri-op
• Consider ICU for fluid management
• Renal disease
• Extensive GI manipulation or resection
• Chronic respiratory disease
• Close monitoring in first 12 hours post-op
• Third space mobilization of extracellular fluid begins 4872 hours post-op
• May cause late onset pulmonary edema
• Tachypnea
• Oxygen saturation drops
Bones and Joints
•
Osteoporosis/penia
•
Osteo/rheumatoid arthritis
•
Hip/spinal fractures
•
Joint replacements
•
Positioning concerns
• Candy canes
• Allen’s/yellofins
•
Post-op ambulation
• PT
• OT
• Home health and family assistance
Medications
• Review all (with herbals)
• Unpredictable in older patients
• Many drug trials exclude elderly
• Multiple medications and interactions
• Start low and go slow
• Body fat increases relative to skeletal muscle mass leading
to changes in drug distribution and absorption
• Drug clearance decreases with renal function slowing and
possibly hepatic changes
Medications
Adverse
Consequences
Drug
•
Insulin
•
Hypoglycemia
•
Warfarin
•
Bleeding
•
Digoxin
•
Impaired cogn., heart block
•
Benzodiazepines
•
Falls
•
Antihistamines-first gen.
•
Sedation, urinary retention
•
Opioids
•
Constip., sed.,confusion, etc.
•
Antipsychotics
•
Death, pneumonia
Medications
Drug
• Fluoroquinolones
Adverse
Consequences
• Tendon rup.,hypoglyc.,
arrhythmia, C. diff.
• Nitrofurantoin
• Pulm. Tox., hepatotox.
• TMP-SMX (Bactrim)
• Hyperkalemia,
hypoglycemia, derm. rxn
Medications
•
Estrogen
• Stop at least 1-2 wk before surgery
•
See anticoagulants
•
Other blood thinning agents or medications that may promote
hypercoagulation (vit E, fish oil, etc.)
•
HTN Rx
• Beta blockers continued pre- and post-op
• Allow anesthesiology to manage because affects their intra-op mgt
• Follow BPs post-op before restarting all meds except beta-blockers
which must be continued
•
Fluid medications (lasix, etc.) affect fluid mgt/output/retention
Prior Surgeries
• Obtain op notes
• Imaging
• If likely to affect case
• Abd v. L/S v. Robotic v. Vaginal
• Consider if back-up/consultants available for
surgical site
Pre-op Imaging/Testing
• Routine imaging—limited data
• MRI for urethral diverticulum
• Cystourethroscopy
•
•
•
•
•
Hematuria
Prior mesh/POP surgery
Bladder pain
Unclear complaints
Evaluate ureteral efflux for apical procedures
• CT, MRI and U/S
• Mass
• Metastatic disease
• No substitute for tissue
• Preop chest x-rays
• Over 60yo
• Cardiac or pulmonary disease
• IVP (intravenous pyelogram)
• Prior ureteral surgery or possible entrapment
• Not cost-effective for pre-op screening
• Does not reduce risk of ureteral injury
• Routine placement of ureteral stents
• No reduced risk
• ? Association with fibrosis and hematuria
• Renal U/S
• Stage IV prolapse
• Possible ureteral obstruction
• Incomplete bladder emptying
• Procto-sigmoidoscopy/anoscopy
•
•
•
•
•
•
Prior posterior mesh
Possible cancer
Blood per rectum
Unclear presentation
Anal fissure
Fistula-in-ano
• Defecography or Dynamic
MRI or Sitz Marker Study
• Severe defecatory
dysfunction
• Defecatory dysfunction not
improved with medical mgt.
• Urodynamics studies
• Controversial when to perform
• Incomplete bladder emptying
• To evaluate bladder pressure
• Concern is upper tract damage
•
•
•
•
•
Mixed symptoms
Failed medical mgt.
Prior anti-incontinence or POP surgery
Consider simple cystometry
Consider bladder backfill with cough test
• w/ or w/o POP reduction
• Semi-recumbant and/or standing
When I was young and foolish, I thought that love made the world go round.
When I got older, I thought it was money. Now I think it is prunes.
True or false: Medical providers can
determine a patient’s mental competence.
• A. True
• B. False
• C. I do not care. Just let me out of here.
Decision-Making Capacity
• Answer: B
• Competence—determined by legal judge
• Capacity—clinical term
• Not legal term
• Does not require judge or psychiatrist
• Can patient reason
• Can she express her goals
• Can she explain her options in her own terms
• Consider asking family/friend whether or not she is acting like
herself
Cognitive Function
• Mini-Cog
• Patient listens to 3 unrelated words and repeats
• Patient draws face of clock then draws clock hands to a
stated time
• Patient repeats 3 words
• Scoring
Living Wills, Etc.
• Advance Directives
• Allow patients to have their wishes/intentions followed
when they can no longer decide for themselves
• Living Wills
•
•
•
•
State wishes regarding specific medical treatments
Given to dr., hospital, etc.
Part of official medical record
State-specific
• Healthcare Power of Attorney
• Durable power of attorney for healthcare
• Agent makes healthcare decisions if pt unable to do so
• If no document: providers/institutions make critical
decisions
General
•
Involve others
• Family
• Understand social support
• Home situation
• Many surgeries are not emergencies
• Get support in place
• Be aware of other social concerns—vacations, reunions, weddings, graduations,
etc.
• PCP, cardiology, pulmonary, etc.
• Do not try to be a hero; let others play their roles
• You then can focus on yours
•
Be slow and cautious with fluids
•
Older patients have more problems (usually)
General
• When possible
• Less invasive is better
• Shorter/quicker is better (while still being safe)
• Consider local/regional anesthesia
Agnes, your uterus is showing again.