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Surgery_Schwartz_13302 | Surgery_Schwartz | the airway with a cuffed endotracheal tube without ever mask ventilating a patient. It is intended to prevent vomiting and aspiration, and it is routinely employed in patients at heightened risk for aspiration. There are no randomized con-trolled trials that demonstrate any kind of outcome benefit of rapid sequence induction in such patients, but it is nevertheless routinely employed for this purpose in the United States.Pediatric patients are often not amenable to preoperative IV catheter placement. Hence, inhalation induction of anesthe-sia is commonly used in children, with IV placement occur-ring after induction. Even among children, however, patients at heightened risk for aspiration or with a full stomach may be best managed with preoperative IV placement and an IV induction. Patients with developmental delay may not be amenable to pre-operative IV placement or inhalational induction of anesthesia. In such patients, intramuscular administration of an agent such as ketamine is | Surgery_Schwartz. the airway with a cuffed endotracheal tube without ever mask ventilating a patient. It is intended to prevent vomiting and aspiration, and it is routinely employed in patients at heightened risk for aspiration. There are no randomized con-trolled trials that demonstrate any kind of outcome benefit of rapid sequence induction in such patients, but it is nevertheless routinely employed for this purpose in the United States.Pediatric patients are often not amenable to preoperative IV catheter placement. Hence, inhalation induction of anesthe-sia is commonly used in children, with IV placement occur-ring after induction. Even among children, however, patients at heightened risk for aspiration or with a full stomach may be best managed with preoperative IV placement and an IV induction. Patients with developmental delay may not be amenable to pre-operative IV placement or inhalational induction of anesthesia. In such patients, intramuscular administration of an agent such as ketamine is | [
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Surgery_Schwartz_13303 | Surgery_Schwartz | with developmental delay may not be amenable to pre-operative IV placement or inhalational induction of anesthesia. In such patients, intramuscular administration of an agent such as ketamine is often required to induce anesthesia.Airway Management. Most anesthesiologists prefer to secure the airway of a patient undergoing general anesthesia, and this is usually accomplished immediately after anesthesia has been induced. The airway may be managed in several ways, includ-ing by face mask, with a laryngeal mask airway (LMA), or, most definitively, by endotracheal intubation with a cuffed endotracheal tube. Nasal and oral airways can help establish a patent airway in a patient being ventilated with a mask by creat-ing an air passage behind the tongue.The LMA is a cuffed supraglottic oral airway that is inserted through the oropharynx and ideally positioned just above the glottis opening. It is passed blindly, and the inflated cuff creates a seal around the laryngeal inlet. An LMA does | Surgery_Schwartz. with developmental delay may not be amenable to pre-operative IV placement or inhalational induction of anesthesia. In such patients, intramuscular administration of an agent such as ketamine is often required to induce anesthesia.Airway Management. Most anesthesiologists prefer to secure the airway of a patient undergoing general anesthesia, and this is usually accomplished immediately after anesthesia has been induced. The airway may be managed in several ways, includ-ing by face mask, with a laryngeal mask airway (LMA), or, most definitively, by endotracheal intubation with a cuffed endotracheal tube. Nasal and oral airways can help establish a patent airway in a patient being ventilated with a mask by creat-ing an air passage behind the tongue.The LMA is a cuffed supraglottic oral airway that is inserted through the oropharynx and ideally positioned just above the glottis opening. It is passed blindly, and the inflated cuff creates a seal around the laryngeal inlet. An LMA does | [
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Surgery_Schwartz_13304 | Surgery_Schwartz | that is inserted through the oropharynx and ideally positioned just above the glottis opening. It is passed blindly, and the inflated cuff creates a seal around the laryngeal inlet. An LMA does not protect against aspiration and should generally not be used in patients with a high risk of aspiration.Tracheal intubation requires a skilled operator and proper equipment. In most elective anesthetics, attempts to intubate the trachea are facilitated by the administration of muscle relaxants in a patient who is already under a general anesthetic. Intubation is typically performed under direct visualization with a laryn-goscope, watching the endotracheal tube pass through the vocal cords into the trachea. To obtain a direct line of sight, the patient is placed in the sniffing position. The neck is flexed at the lower cervical spine and extended at the atlanto-occipital joint. This flexion and extension are amplified during laryngoscopy. Laryn-goscope blades can be curved (Macintosh) or | Surgery_Schwartz. that is inserted through the oropharynx and ideally positioned just above the glottis opening. It is passed blindly, and the inflated cuff creates a seal around the laryngeal inlet. An LMA does not protect against aspiration and should generally not be used in patients with a high risk of aspiration.Tracheal intubation requires a skilled operator and proper equipment. In most elective anesthetics, attempts to intubate the trachea are facilitated by the administration of muscle relaxants in a patient who is already under a general anesthetic. Intubation is typically performed under direct visualization with a laryn-goscope, watching the endotracheal tube pass through the vocal cords into the trachea. To obtain a direct line of sight, the patient is placed in the sniffing position. The neck is flexed at the lower cervical spine and extended at the atlanto-occipital joint. This flexion and extension are amplified during laryngoscopy. Laryn-goscope blades can be curved (Macintosh) or | [
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] |
Surgery_Schwartz_13305 | Surgery_Schwartz | neck is flexed at the lower cervical spine and extended at the atlanto-occipital joint. This flexion and extension are amplified during laryngoscopy. Laryn-goscope blades can be curved (Macintosh) or straight (Miller) blades. Laryngoscopic views are typically reported in a classi-fication system developed by Cormack and Lehane (Fig. 46-5).Management of the Difficult Airway. Some patients have physical characteristics or a history suggestive of difficulty in placing an endotracheal tube. A short neck, limited neck mobil-ity, small interincisor distance, short thyromental distance, and high Mallampati classes may all represent a challenge to Figure 46-5. Laryngoscopic views obtained per Cormack and Lehane.Figure 46-6. Video laryngoscopy with the GlideScope.endotracheal intubation. Several tools have been developed to assist in management of the difficult airway.The Glidescope, a video laryngoscope, allows for visualiza-tion of the larynx on a video screen (Fig. 46-6). Having more of a | Surgery_Schwartz. neck is flexed at the lower cervical spine and extended at the atlanto-occipital joint. This flexion and extension are amplified during laryngoscopy. Laryn-goscope blades can be curved (Macintosh) or straight (Miller) blades. Laryngoscopic views are typically reported in a classi-fication system developed by Cormack and Lehane (Fig. 46-5).Management of the Difficult Airway. Some patients have physical characteristics or a history suggestive of difficulty in placing an endotracheal tube. A short neck, limited neck mobil-ity, small interincisor distance, short thyromental distance, and high Mallampati classes may all represent a challenge to Figure 46-5. Laryngoscopic views obtained per Cormack and Lehane.Figure 46-6. Video laryngoscopy with the GlideScope.endotracheal intubation. Several tools have been developed to assist in management of the difficult airway.The Glidescope, a video laryngoscope, allows for visualiza-tion of the larynx on a video screen (Fig. 46-6). Having more of a | [
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] |
Surgery_Schwartz_13306 | Surgery_Schwartz | tools have been developed to assist in management of the difficult airway.The Glidescope, a video laryngoscope, allows for visualiza-tion of the larynx on a video screen (Fig. 46-6). Having more of a bend than a standard curved Macintosh blade, it can be advanta-geous for visualizing and intubating the trachea in patients with large tongues or relatively anterior glottis openings. Placement of the endotracheal tube once the larynx has been visualized can still be challenging. A recent study of ICU patients requiring intubation showed that video laryngoscopy did not improve first-pass orotracheal intubation success rate and was associated with higher rates of severe life-threatening complications.54The intubating laryngeal mask airway (ILMA) is an advanced form of LMA designed to maintain a patent airway and facilitate tracheal intubation. The ILMA can be placed in anticipated or unexpectedly difficult airways as an airway res-cue device and as a guide for intubating the trachea. The | Surgery_Schwartz. tools have been developed to assist in management of the difficult airway.The Glidescope, a video laryngoscope, allows for visualiza-tion of the larynx on a video screen (Fig. 46-6). Having more of a bend than a standard curved Macintosh blade, it can be advanta-geous for visualizing and intubating the trachea in patients with large tongues or relatively anterior glottis openings. Placement of the endotracheal tube once the larynx has been visualized can still be challenging. A recent study of ICU patients requiring intubation showed that video laryngoscopy did not improve first-pass orotracheal intubation success rate and was associated with higher rates of severe life-threatening complications.54The intubating laryngeal mask airway (ILMA) is an advanced form of LMA designed to maintain a patent airway and facilitate tracheal intubation. The ILMA can be placed in anticipated or unexpectedly difficult airways as an airway res-cue device and as a guide for intubating the trachea. The | [
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Surgery_Schwartz_13307 | Surgery_Schwartz | a patent airway and facilitate tracheal intubation. The ILMA can be placed in anticipated or unexpectedly difficult airways as an airway res-cue device and as a guide for intubating the trachea. The device itself is substantially more rigid than other laryngeal mask airways, and includes a handle which the operator can use to displace the opening of the device. A specially manufactured endotracheal tube can be passed blindly through the ILMA into the larynx, or the ILMA can be used as a conduit for a flex-ible fiberoptic scope. Experience with airway management in general and the use of this device in particular is essential for its effective use in emergency situations; operators with little experience will enjoy little success with this device.The flexible fiberoptic intubation bronchoscope is the gold standard for difficult intubation. It is indicated in difficult or compromised airways where neck extension is not desirable or in cases with risk of dental damage. The flexible | Surgery_Schwartz. a patent airway and facilitate tracheal intubation. The ILMA can be placed in anticipated or unexpectedly difficult airways as an airway res-cue device and as a guide for intubating the trachea. The device itself is substantially more rigid than other laryngeal mask airways, and includes a handle which the operator can use to displace the opening of the device. A specially manufactured endotracheal tube can be passed blindly through the ILMA into the larynx, or the ILMA can be used as a conduit for a flex-ible fiberoptic scope. Experience with airway management in general and the use of this device in particular is essential for its effective use in emergency situations; operators with little experience will enjoy little success with this device.The flexible fiberoptic intubation bronchoscope is the gold standard for difficult intubation. It is indicated in difficult or compromised airways where neck extension is not desirable or in cases with risk of dental damage. The flexible | [
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] |
Surgery_Schwartz_13308 | Surgery_Schwartz | is the gold standard for difficult intubation. It is indicated in difficult or compromised airways where neck extension is not desirable or in cases with risk of dental damage. The flexible bronchoscope allows excellent visualization of the airway and glottic open-ing. This technique can be used for oral and nasal intubation, for awake or asleep intubation, and for intubation in the awake, spontaneously ventilating patient whose airway has been treated with topical local anesthetic.The ASA has developed an algorithm for management of the difficult airway (Fig. 46-7).55 Notably, in patients in whom Brunicardi_Ch46_p2027-p2044.indd 203701/03/19 11:04 AM 2038SPECIFIC CONSIDERATIONSPART IIFigure 46-7. ASA difficult airway algorithm. (Reproduced with permission from Apfelbaum JL, Hagberg CA, Caplan RA, et al: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway, | Surgery_Schwartz. is the gold standard for difficult intubation. It is indicated in difficult or compromised airways where neck extension is not desirable or in cases with risk of dental damage. The flexible bronchoscope allows excellent visualization of the airway and glottic open-ing. This technique can be used for oral and nasal intubation, for awake or asleep intubation, and for intubation in the awake, spontaneously ventilating patient whose airway has been treated with topical local anesthetic.The ASA has developed an algorithm for management of the difficult airway (Fig. 46-7).55 Notably, in patients in whom Brunicardi_Ch46_p2027-p2044.indd 203701/03/19 11:04 AM 2038SPECIFIC CONSIDERATIONSPART IIFigure 46-7. ASA difficult airway algorithm. (Reproduced with permission from Apfelbaum JL, Hagberg CA, Caplan RA, et al: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway, | [
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Surgery_Schwartz_13309 | Surgery_Schwartz | CA, Caplan RA, et al: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway, Anesthesiology. 2013 Feb;118(2):251-270.)Brunicardi_Ch46_p2027-p2044.indd 203801/03/19 11:04 AM 2039ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46both intubation and ventilation are impossible, the algorithm calls for placement of an LMA with ventilation attempted through the LMA.Monitored Anesthesia CareMonitored anesthesia care (MAC) is when a patient under-goes a procedure under local anesthesia under the care of an anesthesiologist who can provide sedation as indicated. Seda-tion is administered to a level that allows the patient to main-tain airway reflexes and breath spontaneously. Advantages of MAC anesthesia include reduced invasiveness, as the airway is not manipulated, and faster recovery. ASA standard moni-tors must be used, including capnography, which allows for rapid detection of | Surgery_Schwartz. CA, Caplan RA, et al: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway, Anesthesiology. 2013 Feb;118(2):251-270.)Brunicardi_Ch46_p2027-p2044.indd 203801/03/19 11:04 AM 2039ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46both intubation and ventilation are impossible, the algorithm calls for placement of an LMA with ventilation attempted through the LMA.Monitored Anesthesia CareMonitored anesthesia care (MAC) is when a patient under-goes a procedure under local anesthesia under the care of an anesthesiologist who can provide sedation as indicated. Seda-tion is administered to a level that allows the patient to main-tain airway reflexes and breath spontaneously. Advantages of MAC anesthesia include reduced invasiveness, as the airway is not manipulated, and faster recovery. ASA standard moni-tors must be used, including capnography, which allows for rapid detection of | [
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Surgery_Schwartz_13310 | Surgery_Schwartz | of MAC anesthesia include reduced invasiveness, as the airway is not manipulated, and faster recovery. ASA standard moni-tors must be used, including capnography, which allows for rapid detection of apnea or hypoventilation. In some instances, most commonly for gastroenterology procedures, patients are administered an intravenous anesthetic that is often classified as a MAC, even though the patient is so deeply anesthetized that they have no significant response to significant airway stimula-tion; the airway is monitored by the anesthesia provider and secured if necessary.Regional Anesthesia/Acute PainRegional anesthesia allows for selective blockade and is an excellent anesthetic option for several different types of pro-cedures. Regional anesthesia can also provide excellent post-operative pain control. Regional techniques include neuraxial blockade, including spinal and epidural anesthetics, peripheral nerve blocks, and truncal blocks.Spinal anesthetics (also referred to as | Surgery_Schwartz. of MAC anesthesia include reduced invasiveness, as the airway is not manipulated, and faster recovery. ASA standard moni-tors must be used, including capnography, which allows for rapid detection of apnea or hypoventilation. In some instances, most commonly for gastroenterology procedures, patients are administered an intravenous anesthetic that is often classified as a MAC, even though the patient is so deeply anesthetized that they have no significant response to significant airway stimula-tion; the airway is monitored by the anesthesia provider and secured if necessary.Regional Anesthesia/Acute PainRegional anesthesia allows for selective blockade and is an excellent anesthetic option for several different types of pro-cedures. Regional anesthesia can also provide excellent post-operative pain control. Regional techniques include neuraxial blockade, including spinal and epidural anesthetics, peripheral nerve blocks, and truncal blocks.Spinal anesthetics (also referred to as | [
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Surgery_Schwartz_13311 | Surgery_Schwartz | pain control. Regional techniques include neuraxial blockade, including spinal and epidural anesthetics, peripheral nerve blocks, and truncal blocks.Spinal anesthetics (also referred to as subarachnoid blocks) can be used for lower extremity, lower abdominal, pelvic, and urologic and gynecologic procedures. A small caliber needle (typically 25-gauge or smaller) is inserted into the intrathecal space in the cauda aquina and below the conus medularis, and a small volume of local anesthetic is injected. Duration and level of the block in the spinal cord is affected by the anesthetic used, the dose employed, and baricity of solution injected. Complica-tions can include hypotension, bradycardia, postdural puncture headache, injury to local structures or nerves, and hematoma formation. The American Society of Regional Anesthesia pub-lishes guidelines regarding safe intervals to perform neuraxial anesthetics after the administration of anticoagulant and anti-platelet agents.An epidural | Surgery_Schwartz. pain control. Regional techniques include neuraxial blockade, including spinal and epidural anesthetics, peripheral nerve blocks, and truncal blocks.Spinal anesthetics (also referred to as subarachnoid blocks) can be used for lower extremity, lower abdominal, pelvic, and urologic and gynecologic procedures. A small caliber needle (typically 25-gauge or smaller) is inserted into the intrathecal space in the cauda aquina and below the conus medularis, and a small volume of local anesthetic is injected. Duration and level of the block in the spinal cord is affected by the anesthetic used, the dose employed, and baricity of solution injected. Complica-tions can include hypotension, bradycardia, postdural puncture headache, injury to local structures or nerves, and hematoma formation. The American Society of Regional Anesthesia pub-lishes guidelines regarding safe intervals to perform neuraxial anesthetics after the administration of anticoagulant and anti-platelet agents.An epidural | [
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Surgery_Schwartz_13312 | Surgery_Schwartz | American Society of Regional Anesthesia pub-lishes guidelines regarding safe intervals to perform neuraxial anesthetics after the administration of anticoagulant and anti-platelet agents.An epidural catheter can be used as a primary anesthetic for a procedure, or it can be placed preoperatively and used in conjunction with a general anesthetic for postoperative pain control. Epidural catheters can be placed in the thoracic or lumbar spine and can remain in place for days after surgery. A dilute local anesthetic and/or opioid is administered through the catheter to provide analgesia. Complications of epidural anesthesia are similar to that of spinal anesthesia. In addition to improved pain control, benefits of epidural anesthesia include reduced pulmonary complications56 and decreased duration of postoperative ileus.57Peripheral nerve blockade can also be used to provide sur-gical anesthesia as well as postoperative analgesia, particularly for surgeries of the upper or lower | Surgery_Schwartz. American Society of Regional Anesthesia pub-lishes guidelines regarding safe intervals to perform neuraxial anesthetics after the administration of anticoagulant and anti-platelet agents.An epidural catheter can be used as a primary anesthetic for a procedure, or it can be placed preoperatively and used in conjunction with a general anesthetic for postoperative pain control. Epidural catheters can be placed in the thoracic or lumbar spine and can remain in place for days after surgery. A dilute local anesthetic and/or opioid is administered through the catheter to provide analgesia. Complications of epidural anesthesia are similar to that of spinal anesthesia. In addition to improved pain control, benefits of epidural anesthesia include reduced pulmonary complications56 and decreased duration of postoperative ileus.57Peripheral nerve blockade can also be used to provide sur-gical anesthesia as well as postoperative analgesia, particularly for surgeries of the upper or lower | [
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Surgery_Schwartz_13313 | Surgery_Schwartz | duration of postoperative ileus.57Peripheral nerve blockade can also be used to provide sur-gical anesthesia as well as postoperative analgesia, particularly for surgeries of the upper or lower extremities. The nerve or plexus of interest is located with ultrasound and/or peripheral nerve stimulator, and local anesthetic is injected around the nerve. Single-shot nerve blocks allow for surgical anesthesia and immediate postoperative analgesia and can last for several hours. Flexible catheters can also be placed in proximity to nerves to allow for continuous infusion and blockade that can continue for several days. Complications of peripheral nerve blocks include injury to nerves or nearby structures and local anesthetic systemic toxicity.Recently, truncal blocks have become more commonly and widely used for the treatment of postoperative pain. Trun-cal blocks include the transversus abdominis plane (TAP) block, the rectus sheath block, the pectoral nerve block, and the serra-tus | Surgery_Schwartz. duration of postoperative ileus.57Peripheral nerve blockade can also be used to provide sur-gical anesthesia as well as postoperative analgesia, particularly for surgeries of the upper or lower extremities. The nerve or plexus of interest is located with ultrasound and/or peripheral nerve stimulator, and local anesthetic is injected around the nerve. Single-shot nerve blocks allow for surgical anesthesia and immediate postoperative analgesia and can last for several hours. Flexible catheters can also be placed in proximity to nerves to allow for continuous infusion and blockade that can continue for several days. Complications of peripheral nerve blocks include injury to nerves or nearby structures and local anesthetic systemic toxicity.Recently, truncal blocks have become more commonly and widely used for the treatment of postoperative pain. Trun-cal blocks include the transversus abdominis plane (TAP) block, the rectus sheath block, the pectoral nerve block, and the serra-tus | [
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Surgery_Schwartz_13314 | Surgery_Schwartz | and widely used for the treatment of postoperative pain. Trun-cal blocks include the transversus abdominis plane (TAP) block, the rectus sheath block, the pectoral nerve block, and the serra-tus anterior plane block. These truncal blocks are usually done under ultrasound guidance with local anesthetic injected in the appropriate plane. Truncal blocks are typically performed as part of a multimodal approach to postoperative pain. Limited evidence suggests that use of truncal blocks decreases postop-erative opioid requirements.58,59RECOVERY AND COMPLICATIONSThe Postanesthesia Care UnitThe advent of the modern postanesthesia care unit represents a major advance in the safety of perioperative care, as the close monitoring that occurs there can prevent or expedite the man-agement of a variety of serious complications. Ventilation, oxygenation, hemodynamics, temperature, nausea, and pain are closely monitored in the PACU, with close attention also given to urine output, ongoing bleeding, | Surgery_Schwartz. and widely used for the treatment of postoperative pain. Trun-cal blocks include the transversus abdominis plane (TAP) block, the rectus sheath block, the pectoral nerve block, and the serra-tus anterior plane block. These truncal blocks are usually done under ultrasound guidance with local anesthetic injected in the appropriate plane. Truncal blocks are typically performed as part of a multimodal approach to postoperative pain. Limited evidence suggests that use of truncal blocks decreases postop-erative opioid requirements.58,59RECOVERY AND COMPLICATIONSThe Postanesthesia Care UnitThe advent of the modern postanesthesia care unit represents a major advance in the safety of perioperative care, as the close monitoring that occurs there can prevent or expedite the man-agement of a variety of serious complications. Ventilation, oxygenation, hemodynamics, temperature, nausea, and pain are closely monitored in the PACU, with close attention also given to urine output, ongoing bleeding, | [
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Surgery_Schwartz_13315 | Surgery_Schwartz | of serious complications. Ventilation, oxygenation, hemodynamics, temperature, nausea, and pain are closely monitored in the PACU, with close attention also given to urine output, ongoing bleeding, and drainage. To be dis-charge eligible, patients should have returned to their baseline mental status, be oxygenating and ventilating adequately, have adequate pain control, and have stable vital signs. There are multiple scoring systems that can be used assess suitability for discharge from PACU.60-62 Postoperative hemorrhage, hyper-tension or hypotension, myocardial ischemia, arrhythmias, and altered mental status commonly manifest in the postoperative care unit. Postoperative nausea and vomiting (PONV) occurs in 20% to 30% of surgical cases,63 and it is a common cause of increased PACU length of stay and increased cost of PACU stay.64 For this reason, many or most patients undergoing gen-eral anesthesia receive prophylactic antiemetics.Enhanced Recovery After Surgery PathwaysEnhanced | Surgery_Schwartz. of serious complications. Ventilation, oxygenation, hemodynamics, temperature, nausea, and pain are closely monitored in the PACU, with close attention also given to urine output, ongoing bleeding, and drainage. To be dis-charge eligible, patients should have returned to their baseline mental status, be oxygenating and ventilating adequately, have adequate pain control, and have stable vital signs. There are multiple scoring systems that can be used assess suitability for discharge from PACU.60-62 Postoperative hemorrhage, hyper-tension or hypotension, myocardial ischemia, arrhythmias, and altered mental status commonly manifest in the postoperative care unit. Postoperative nausea and vomiting (PONV) occurs in 20% to 30% of surgical cases,63 and it is a common cause of increased PACU length of stay and increased cost of PACU stay.64 For this reason, many or most patients undergoing gen-eral anesthesia receive prophylactic antiemetics.Enhanced Recovery After Surgery PathwaysEnhanced | [
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Surgery_Schwartz_13316 | Surgery_Schwartz | of stay and increased cost of PACU stay.64 For this reason, many or most patients undergoing gen-eral anesthesia receive prophylactic antiemetics.Enhanced Recovery After Surgery PathwaysEnhanced recovery after surgery (ERAS) pathways are multi-modal perioperative care pathways designed to hasten recovery after elective surgery. These pathways may include preoperative education and counseling, preoperative optimization, limiting preoperative bowel preparation, limiting preoperative fasting, providing multimodal analgesia (including regional anesthesia) as appropriate, minimizing intraoperative fluid administration, and early mobilization. ERAS pathways have been shown to reduce duration of hospitalization and reduce cost of periopera-tive care.65-67Acute Postoperative PainThe management of postoperative pain has changed dra-matically in the modern era, with multimodal approaches and regional techniques reducing the use of opiates. Regardless, opioids remain the mainstay of | Surgery_Schwartz. of stay and increased cost of PACU stay.64 For this reason, many or most patients undergoing gen-eral anesthesia receive prophylactic antiemetics.Enhanced Recovery After Surgery PathwaysEnhanced recovery after surgery (ERAS) pathways are multi-modal perioperative care pathways designed to hasten recovery after elective surgery. These pathways may include preoperative education and counseling, preoperative optimization, limiting preoperative bowel preparation, limiting preoperative fasting, providing multimodal analgesia (including regional anesthesia) as appropriate, minimizing intraoperative fluid administration, and early mobilization. ERAS pathways have been shown to reduce duration of hospitalization and reduce cost of periopera-tive care.65-67Acute Postoperative PainThe management of postoperative pain has changed dra-matically in the modern era, with multimodal approaches and regional techniques reducing the use of opiates. Regardless, opioids remain the mainstay of | [
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Surgery_Schwartz_13317 | Surgery_Schwartz | of postoperative pain has changed dra-matically in the modern era, with multimodal approaches and regional techniques reducing the use of opiates. Regardless, opioids remain the mainstay of intraoperative and postoperative analgesia, especially for larger and more invasive procedures. Patients with chronic pain or opiate tolerance can present a unique challenge in the perioperative period, and they can ben-efit from regional and multimodal approaches. Such patients may benefit from early involvement of an acute pain medicine specialist.For the past decade, pain has been described as the fifth vital sign, and physicians have been strongly encouraged to 5Brunicardi_Ch46_p2027-p2044.indd 203901/03/19 11:04 AM 2040SPECIFIC CONSIDERATIONSPART IIaggressively treat pain in their patients. Generally speaking, physicians sought to accomplish this goal through the more liberal use of opiates. Opioid prescription has thus soared in recent years. Some studies suggest that 3% to 7% of surgical | Surgery_Schwartz. of postoperative pain has changed dra-matically in the modern era, with multimodal approaches and regional techniques reducing the use of opiates. Regardless, opioids remain the mainstay of intraoperative and postoperative analgesia, especially for larger and more invasive procedures. Patients with chronic pain or opiate tolerance can present a unique challenge in the perioperative period, and they can ben-efit from regional and multimodal approaches. Such patients may benefit from early involvement of an acute pain medicine specialist.For the past decade, pain has been described as the fifth vital sign, and physicians have been strongly encouraged to 5Brunicardi_Ch46_p2027-p2044.indd 203901/03/19 11:04 AM 2040SPECIFIC CONSIDERATIONSPART IIaggressively treat pain in their patients. Generally speaking, physicians sought to accomplish this goal through the more liberal use of opiates. Opioid prescription has thus soared in recent years. Some studies suggest that 3% to 7% of surgical | [
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Surgery_Schwartz_13318 | Surgery_Schwartz | speaking, physicians sought to accomplish this goal through the more liberal use of opiates. Opioid prescription has thus soared in recent years. Some studies suggest that 3% to 7% of surgical patients prescribed opioids in the postoperative period continue to use them for a prolonged period after surgery,68,69 suggesting that opioid abuse often begins in the postoperative period. The U.S. Centers for Disease Control and Prevention has recently declared that prescription drug abuse is an epidemic.70 Physi-cians and surgeons will have to continue to seek the fine line between adequate pain control and prescribing patterns that enable dependence.Malignant HyperthermiaMalignant hyperthermia (MH) is a hereditary, life-threatening, hypermetabolic disorder, developing during or after receiving general anesthesia. The clinical incidence of MH ranges from 1:10000 to 1:250,000.71 A genetic predisposition and expo-sure to one or more triggering agents are necessary to evoke MH. Triggering | Surgery_Schwartz. speaking, physicians sought to accomplish this goal through the more liberal use of opiates. Opioid prescription has thus soared in recent years. Some studies suggest that 3% to 7% of surgical patients prescribed opioids in the postoperative period continue to use them for a prolonged period after surgery,68,69 suggesting that opioid abuse often begins in the postoperative period. The U.S. Centers for Disease Control and Prevention has recently declared that prescription drug abuse is an epidemic.70 Physi-cians and surgeons will have to continue to seek the fine line between adequate pain control and prescribing patterns that enable dependence.Malignant HyperthermiaMalignant hyperthermia (MH) is a hereditary, life-threatening, hypermetabolic disorder, developing during or after receiving general anesthesia. The clinical incidence of MH ranges from 1:10000 to 1:250,000.71 A genetic predisposition and expo-sure to one or more triggering agents are necessary to evoke MH. Triggering | [
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Surgery_Schwartz_13319 | Surgery_Schwartz | general anesthesia. The clinical incidence of MH ranges from 1:10000 to 1:250,000.71 A genetic predisposition and expo-sure to one or more triggering agents are necessary to evoke MH. Triggering agents include all volatile anesthetics (e.g., isoflurane, sevoflurane, and desflurane) and the depolarizing neuromuscular blocker succinylcholine. Volatile anesthetics and/or succinylcholine cause a rise in the myoplasmic cal-cium concentration in susceptible patients, causing persistent muscle contraction, the production of large quantities of car-bon dioxide and lactic acid, and a relentless increase in body temperature.MH is often an autosomal dominant disorder associated with several gene loci, predominantly the ryanodine receptor gene RYR1. MH can be diagnosed with the caffeine-contracture halothane test, which requires a muscle biopsy. Genetic testing can be helpful after an episode of MH. There is no simple, reli-able blood screening test yet available for diagnosis.The classic MH | Surgery_Schwartz. general anesthesia. The clinical incidence of MH ranges from 1:10000 to 1:250,000.71 A genetic predisposition and expo-sure to one or more triggering agents are necessary to evoke MH. Triggering agents include all volatile anesthetics (e.g., isoflurane, sevoflurane, and desflurane) and the depolarizing neuromuscular blocker succinylcholine. Volatile anesthetics and/or succinylcholine cause a rise in the myoplasmic cal-cium concentration in susceptible patients, causing persistent muscle contraction, the production of large quantities of car-bon dioxide and lactic acid, and a relentless increase in body temperature.MH is often an autosomal dominant disorder associated with several gene loci, predominantly the ryanodine receptor gene RYR1. MH can be diagnosed with the caffeine-contracture halothane test, which requires a muscle biopsy. Genetic testing can be helpful after an episode of MH. There is no simple, reli-able blood screening test yet available for diagnosis.The classic MH | [
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Surgery_Schwartz_13320 | Surgery_Schwartz | halothane test, which requires a muscle biopsy. Genetic testing can be helpful after an episode of MH. There is no simple, reli-able blood screening test yet available for diagnosis.The classic MH crisis entails a hypermetabolic state with tachycardia and increased end-tidal CO2. Relentless muscle con-traction causes respiratory and metabolic acidosis, as well as rhabdomyolysis, arrhythmias, hyperkalemia, and even sudden cardiac arrest. Hyperthermia typically occurs after the episode is well under way. Treatment must be aggressive and begin as soon as a case of MH is suspected. Volatile anesthetics should be stopped immediately and dantrolene given at an initial dose of 2.5 mg/kg intravenously. The national MH hotline should be contacted for help in managing any patient with MH. Patients should be monitored in the intensive care setting for possible recrudescence of MH.Cardiovascular ComplicationsHemodynamic perturbations are a common in the periopera-tive period. Arrhythmias may | Surgery_Schwartz. halothane test, which requires a muscle biopsy. Genetic testing can be helpful after an episode of MH. There is no simple, reli-able blood screening test yet available for diagnosis.The classic MH crisis entails a hypermetabolic state with tachycardia and increased end-tidal CO2. Relentless muscle con-traction causes respiratory and metabolic acidosis, as well as rhabdomyolysis, arrhythmias, hyperkalemia, and even sudden cardiac arrest. Hyperthermia typically occurs after the episode is well under way. Treatment must be aggressive and begin as soon as a case of MH is suspected. Volatile anesthetics should be stopped immediately and dantrolene given at an initial dose of 2.5 mg/kg intravenously. The national MH hotline should be contacted for help in managing any patient with MH. Patients should be monitored in the intensive care setting for possible recrudescence of MH.Cardiovascular ComplicationsHemodynamic perturbations are a common in the periopera-tive period. Arrhythmias may | [
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Surgery_Schwartz_13321 | Surgery_Schwartz | should be monitored in the intensive care setting for possible recrudescence of MH.Cardiovascular ComplicationsHemodynamic perturbations are a common in the periopera-tive period. Arrhythmias may begin before, during, and after an anesthetic, and are particularly common after cardiothoracic and esophageal surgery. Hypotension may be due to anemia, hypovolemia, myocardial ischemia or dysfunction, or other less common events such as pulmonary embolism and ana-phylactic reactions. Hypertension is also common, particularly when antihypertensive regimens are altered in the perioperative period.Respiratory FailureRespiratory insufficiency and failure occur frequently in the postoperative period. Respiratory depression can occur as a con-sequence of residual neuromuscular blockade, residual inhaled anesthetics, or opioids. Mechanical airway obstruction can be ameliorated by rescue maneuvers, or insertion of an oral or nasal airway. It is imperative to evaluate and treat anesthesia-related | Surgery_Schwartz. should be monitored in the intensive care setting for possible recrudescence of MH.Cardiovascular ComplicationsHemodynamic perturbations are a common in the periopera-tive period. Arrhythmias may begin before, during, and after an anesthetic, and are particularly common after cardiothoracic and esophageal surgery. Hypotension may be due to anemia, hypovolemia, myocardial ischemia or dysfunction, or other less common events such as pulmonary embolism and ana-phylactic reactions. Hypertension is also common, particularly when antihypertensive regimens are altered in the perioperative period.Respiratory FailureRespiratory insufficiency and failure occur frequently in the postoperative period. Respiratory depression can occur as a con-sequence of residual neuromuscular blockade, residual inhaled anesthetics, or opioids. Mechanical airway obstruction can be ameliorated by rescue maneuvers, or insertion of an oral or nasal airway. It is imperative to evaluate and treat anesthesia-related | [
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Surgery_Schwartz_13322 | Surgery_Schwartz | anesthetics, or opioids. Mechanical airway obstruction can be ameliorated by rescue maneuvers, or insertion of an oral or nasal airway. It is imperative to evaluate and treat anesthesia-related causes of respiratory insufficiency. The opioid antagonist nalox-one can be given for opioid related respiratory insufficiency, and an additional reversal agent can be given for residual neuromus-cular weakness. Respiratory failure can reasonably be managed with noninvasive positive pressure ventilation in many cases72; patients who fail this or are unlikely to benefit from it should be intubated. High-flow nasal cannula is increasingly being used for postextubation respiratory failure,73 and several studies have demonstrated its benefit in postoperative patients.74-77Neurologic and Psychiatric ComplicationsPerioperative neurologic and psychiatric complications include stroke, both ischemic and hemorrhagic, postoperative delirium, and postoperative cognitive dysfunction. Treatment of | Surgery_Schwartz. anesthetics, or opioids. Mechanical airway obstruction can be ameliorated by rescue maneuvers, or insertion of an oral or nasal airway. It is imperative to evaluate and treat anesthesia-related causes of respiratory insufficiency. The opioid antagonist nalox-one can be given for opioid related respiratory insufficiency, and an additional reversal agent can be given for residual neuromus-cular weakness. Respiratory failure can reasonably be managed with noninvasive positive pressure ventilation in many cases72; patients who fail this or are unlikely to benefit from it should be intubated. High-flow nasal cannula is increasingly being used for postextubation respiratory failure,73 and several studies have demonstrated its benefit in postoperative patients.74-77Neurologic and Psychiatric ComplicationsPerioperative neurologic and psychiatric complications include stroke, both ischemic and hemorrhagic, postoperative delirium, and postoperative cognitive dysfunction. Treatment of | [
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Surgery_Schwartz_13323 | Surgery_Schwartz | ComplicationsPerioperative neurologic and psychiatric complications include stroke, both ischemic and hemorrhagic, postoperative delirium, and postoperative cognitive dysfunction. Treatment of periop-erative stroke may be difficult as initiation of anticoagulation or thrombolysis may not be safe after surgery. Postoperative delirium is common and transient. Treatment includes reorienta-tion, treatment of pain, workup for metabolic, hemodynamic, or respiratory perturbations, and consideration of the side effects of the anesthetics and analgesics administered. Antipsychotics such as haloperidol can be useful in the treatment of postopera-tive delirium.78 Postoperative cognitive dysfunction (POCD) is a decline in cognitive function that may last days or may persist for months. Risk factors for persistent POCD include advanced age, history of prior stroke, and lower educational level.79 POCD rates among older adult patients have been shown to be as high as 40% at hospital discharge and | Surgery_Schwartz. ComplicationsPerioperative neurologic and psychiatric complications include stroke, both ischemic and hemorrhagic, postoperative delirium, and postoperative cognitive dysfunction. Treatment of periop-erative stroke may be difficult as initiation of anticoagulation or thrombolysis may not be safe after surgery. Postoperative delirium is common and transient. Treatment includes reorienta-tion, treatment of pain, workup for metabolic, hemodynamic, or respiratory perturbations, and consideration of the side effects of the anesthetics and analgesics administered. Antipsychotics such as haloperidol can be useful in the treatment of postopera-tive delirium.78 Postoperative cognitive dysfunction (POCD) is a decline in cognitive function that may last days or may persist for months. Risk factors for persistent POCD include advanced age, history of prior stroke, and lower educational level.79 POCD rates among older adult patients have been shown to be as high as 40% at hospital discharge and | [
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Surgery_Schwartz_13324 | Surgery_Schwartz | for persistent POCD include advanced age, history of prior stroke, and lower educational level.79 POCD rates among older adult patients have been shown to be as high as 40% at hospital discharge and 12% 3 months after surgery. Notably, a causal link has not been established between administration of anesthesia and development of POCD, sug-gesting that it may be the physiologic stress of the perioperative experience that may lead to a decline in cognitive function in such patients.80CONCLUSIONThe practice of anesthesia has improved dramatically over the past century. Advances in training, pharmacology, anesthesia equipment, and monitoring have not only made anesthesia dra-matically safer but have also allowed ever sicker patients to benefit from surgery.REFERENCESEntries highlighted in bright blue are key references. 1. Haridas RP. Horace wells’ demonstration of nitrous oxide in Boston. Anesthesiology. 2013;119:1014-1022. 2. Bigelow HJ. insensibility during surgical operations produced | Surgery_Schwartz. for persistent POCD include advanced age, history of prior stroke, and lower educational level.79 POCD rates among older adult patients have been shown to be as high as 40% at hospital discharge and 12% 3 months after surgery. Notably, a causal link has not been established between administration of anesthesia and development of POCD, sug-gesting that it may be the physiologic stress of the perioperative experience that may lead to a decline in cognitive function in such patients.80CONCLUSIONThe practice of anesthesia has improved dramatically over the past century. Advances in training, pharmacology, anesthesia equipment, and monitoring have not only made anesthesia dra-matically safer but have also allowed ever sicker patients to benefit from surgery.REFERENCESEntries highlighted in bright blue are key references. 1. Haridas RP. Horace wells’ demonstration of nitrous oxide in Boston. Anesthesiology. 2013;119:1014-1022. 2. Bigelow HJ. insensibility during surgical operations produced | [
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Surgery_Schwartz_13325 | Surgery_Schwartz | blue are key references. 1. Haridas RP. Horace wells’ demonstration of nitrous oxide in Boston. Anesthesiology. 2013;119:1014-1022. 2. Bigelow HJ. insensibility during surgical operations produced by inhalation. Boston Med Surg J. 1846;35:309-317. This arti-cle, published in the predecessor to the New England Journal of Medicine, described the first public demonstration of ether at the Massachusetts General Hospital. 3. Buckley K. The most important article in NEJM history. 2012. Available at: https://blogs.nejm.org/now/index.php/explore-the-history-of-medical-discoveries/2012/01/26/. Accessed August 20, 2018. 4. Kim TK OS, Johnson KB. Basic Principles of pharmacology. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen N, Young WL, eds. Miller’s Anesthesia. 8th ed. Philadelphia: Elsevier; 2015:590-613. 5. Forman SA, Benkwitz C. Pharmacology of inhalational anesthetics. In: Longnecker DE, Brown DL, Newman MF, Zapol WM, eds. Anesthesiology. New York: McGraw-Hill; | Surgery_Schwartz. blue are key references. 1. Haridas RP. Horace wells’ demonstration of nitrous oxide in Boston. Anesthesiology. 2013;119:1014-1022. 2. Bigelow HJ. insensibility during surgical operations produced by inhalation. Boston Med Surg J. 1846;35:309-317. This arti-cle, published in the predecessor to the New England Journal of Medicine, described the first public demonstration of ether at the Massachusetts General Hospital. 3. Buckley K. The most important article in NEJM history. 2012. Available at: https://blogs.nejm.org/now/index.php/explore-the-history-of-medical-discoveries/2012/01/26/. Accessed August 20, 2018. 4. Kim TK OS, Johnson KB. Basic Principles of pharmacology. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen N, Young WL, eds. Miller’s Anesthesia. 8th ed. Philadelphia: Elsevier; 2015:590-613. 5. Forman SA, Benkwitz C. Pharmacology of inhalational anesthetics. In: Longnecker DE, Brown DL, Newman MF, Zapol WM, eds. Anesthesiology. New York: McGraw-Hill; | [
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Surgery_Schwartz_13327 | Surgery_Schwartz | Newman MF, Zapol WM, eds. Anesthesiology. New York: McGraw-Hill; 2012:687-702. 8. Wagner RL, White PF, Kan PB, et al. Inhibition of adrenal steroidogenesis by the anesthetic etomidate. N Engl J Med. 1984;310:1415-1421. 9. Annane D, Sebille V, Charpentier C, et al. Effect of treat-ment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288: 862-871. 10. McPhee LC, Badawi O, Fraser GL, et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41:774-783. 11. Absalom A, Pledger D, Kong A. Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia. 1999;54:861-867. 12. Hohl CM, Kelly-Smith CH, Yeung TC, et al. The effect of a bolus dose of etomidate on cortisol levels, mortality, and health services utilization: a systematic review. Ann Emerg Med. 2010;56:105-113.e105. 13. Mozanski M, | Surgery_Schwartz. Newman MF, Zapol WM, eds. Anesthesiology. New York: McGraw-Hill; 2012:687-702. 8. Wagner RL, White PF, Kan PB, et al. Inhibition of adrenal steroidogenesis by the anesthetic etomidate. N Engl J Med. 1984;310:1415-1421. 9. Annane D, Sebille V, Charpentier C, et al. Effect of treat-ment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288: 862-871. 10. McPhee LC, Badawi O, Fraser GL, et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41:774-783. 11. Absalom A, Pledger D, Kong A. Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia. 1999;54:861-867. 12. Hohl CM, Kelly-Smith CH, Yeung TC, et al. The effect of a bolus dose of etomidate on cortisol levels, mortality, and health services utilization: a systematic review. Ann Emerg Med. 2010;56:105-113.e105. 13. Mozanski M, | [
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Surgery_Schwartz_13330 | Surgery_Schwartz | systemic toxicity. BJA Educ. 2015;15:136-142. 21. Heavner JE. Pharmacology of local anesthetics. In: Longnecker DE, Brown DL, Newman MF, Zapol WM, eds. Anesthesiology. New York: McGraw-Hill; 2012:767-782. 22. Naguib M, Lien C, Meistelman C. Pharmacology of neuromus-cular blocking drugs. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen N, Young WL, eds. Miller’s Anes-thesia. 8th ed. Philadelphia: Elsevier; 2015:958-994. 23. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg. 2006;102:151-155. 24. Kodali BS, Urman RD. Capnography during cardiopulmonary resuscitation: current evidence and future directions. J Emerg Trauma Shock. 2014;7:332-340. This article reviews the impor-tance of capnography during cardiopulmonary resuscitation. 25. Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med. 2011;365:591-600. | Surgery_Schwartz. systemic toxicity. BJA Educ. 2015;15:136-142. 21. Heavner JE. Pharmacology of local anesthetics. In: Longnecker DE, Brown DL, Newman MF, Zapol WM, eds. Anesthesiology. New York: McGraw-Hill; 2012:767-782. 22. Naguib M, Lien C, Meistelman C. Pharmacology of neuromus-cular blocking drugs. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen N, Young WL, eds. Miller’s Anes-thesia. 8th ed. Philadelphia: Elsevier; 2015:958-994. 23. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg. 2006;102:151-155. 24. Kodali BS, Urman RD. Capnography during cardiopulmonary resuscitation: current evidence and future directions. J Emerg Trauma Shock. 2014;7:332-340. This article reviews the impor-tance of capnography during cardiopulmonary resuscitation. 25. Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med. 2011;365:591-600. | [
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Surgery_Schwartz_13331 | Surgery_Schwartz | during cardiopulmonary resuscitation. 25. Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med. 2011;365:591-600. This landmark study dem-onstrated no reduction of intraoperative awareness rates with use of the bispectral index monitor over monitoring anesthetic gas concentration. 26. Lien CA, Kopman AF. Current recommendations for monitor-ing depth of neuromuscular blockade. Curr Opin Anaesthesiol. 2014;27:616-622. 27. Hopkins TJ, Raghunathan K, Barbeito A, et al. Associations between ASA physical status and postoperative mortality at 48 h: a contemporary dataset analysis compared to a historical cohort. Perioper Med (London, England). 2016;5:29. 28. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434. Dr. Mallampati’s land-mark study set the standard for preoperative airway exami-nation, and the | Surgery_Schwartz. during cardiopulmonary resuscitation. 25. Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med. 2011;365:591-600. This landmark study dem-onstrated no reduction of intraoperative awareness rates with use of the bispectral index monitor over monitoring anesthetic gas concentration. 26. Lien CA, Kopman AF. Current recommendations for monitor-ing depth of neuromuscular blockade. Curr Opin Anaesthesiol. 2014;27:616-622. 27. Hopkins TJ, Raghunathan K, Barbeito A, et al. Associations between ASA physical status and postoperative mortality at 48 h: a contemporary dataset analysis compared to a historical cohort. Perioper Med (London, England). 2016;5:29. 28. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434. Dr. Mallampati’s land-mark study set the standard for preoperative airway exami-nation, and the | [
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Surgery_Schwartz_13332 | Surgery_Schwartz | sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434. Dr. Mallampati’s land-mark study set the standard for preoperative airway exami-nation, and the classification system described assists with prediction of difficult intubation. 29. Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104:1293-1318. 30. Shiga T, Wajima Z, Inoue T, et al. Predicting difficult intuba-tion in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429-437. 31. Riad W, Vaez MN, Raveendran R, et al. Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: a prospective observational study. Eur J Anaesthesiol. 2016;33:244-249. 32. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive | Surgery_Schwartz. sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434. Dr. Mallampati’s land-mark study set the standard for preoperative airway exami-nation, and the classification system described assists with prediction of difficult intubation. 29. Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104:1293-1318. 30. Shiga T, Wajima Z, Inoue T, et al. Predicting difficult intuba-tion in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429-437. 31. Riad W, Vaez MN, Raveendran R, et al. Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: a prospective observational study. Eur J Anaesthesiol. 2016;33:244-249. 32. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive | [
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Surgery_Schwartz_13334 | Surgery_Schwartz | Cochrane Database Syst Rev. 2014;Cd004476. 35. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet (London, England). 2008;371:1839-1847. 36. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the American Society of Anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology. 2011;114:247-261. 37. Mutlu GM, Factor P, Schwartz DE, et al. Severe status asthmat-icus: management with permissive hypercapnia and inhalation anesthesia. Crit Care Med. 2002;30:477-480. 38. American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by | Surgery_Schwartz. Cochrane Database Syst Rev. 2014;Cd004476. 35. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet (London, England). 2008;371:1839-1847. 36. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the American Society of Anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology. 2011;114:247-261. 37. Mutlu GM, Factor P, Schwartz DE, et al. Severe status asthmat-icus: management with permissive hypercapnia and inhalation anesthesia. Crit Care Med. 2002;30:477-480. 38. American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by | [
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Surgery_Schwartz_13336 | Surgery_Schwartz | in coronary artery bypass surgery. Scand Cardiovasc J. 2008;42:392-398. 41. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preopera-tive hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2008;136:631-640. 42. Dhatariya K, Levy N, Kilvert A, et al. NHS Diabetes guideline for the perioperative management of the adult patient with dia-betes. Diabet Med. 2012;29:420-433. 43. Joshi GP, Chung F, Vann MA, et al. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory sur-gery. Anesth Analg. 2010;111:1378-1387. 44. Sudhakaran S, Surani SR. Guidelines for perioperative manage-ment of the diabetic patient. Surg Res Pract. 2015;2015:284063. 45. Sebranek JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(suppl 1):i18-i34. 46. Duncan AE. Hyperglycemia and perioperative glucose man-agement. Curr Pharm | Surgery_Schwartz. in coronary artery bypass surgery. Scand Cardiovasc J. 2008;42:392-398. 41. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preopera-tive hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2008;136:631-640. 42. Dhatariya K, Levy N, Kilvert A, et al. NHS Diabetes guideline for the perioperative management of the adult patient with dia-betes. Diabet Med. 2012;29:420-433. 43. Joshi GP, Chung F, Vann MA, et al. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory sur-gery. Anesth Analg. 2010;111:1378-1387. 44. Sudhakaran S, Surani SR. Guidelines for perioperative manage-ment of the diabetic patient. Surg Res Pract. 2015;2015:284063. 45. Sebranek JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(suppl 1):i18-i34. 46. Duncan AE. Hyperglycemia and perioperative glucose man-agement. Curr Pharm | [
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Surgery_Schwartz_13337 | Surgery_Schwartz | JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(suppl 1):i18-i34. 46. Duncan AE. Hyperglycemia and perioperative glucose man-agement. Curr Pharm Des. 2012;18:6195-6203. 47. Lipshutz AKM, Gropper MA. Perioperative glycemic control: an evidence-based review. Anesthesiology. 2009;110:408-421. 48. American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists com-mittee on standards and practice parameters. Anesthesiology. 2011;114:495-511. 49. American College of Surgeons. Statement on advance direc-tives by patients: “do not resuscitate” in the operating room. Bull Am Coll Surg. 2014;99:42-43. 50. American Society of Anesthesiologists. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate | Surgery_Schwartz. JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(suppl 1):i18-i34. 46. Duncan AE. Hyperglycemia and perioperative glucose man-agement. Curr Pharm Des. 2012;18:6195-6203. 47. Lipshutz AKM, Gropper MA. Perioperative glycemic control: an evidence-based review. Anesthesiology. 2009;110:408-421. 48. American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists com-mittee on standards and practice parameters. Anesthesiology. 2011;114:495-511. 49. American College of Surgeons. Statement on advance direc-tives by patients: “do not resuscitate” in the operating room. Bull Am Coll Surg. 2014;99:42-43. 50. American Society of Anesthesiologists. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate | [
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Surgery_Schwartz_13339 | Surgery_Schwartz | Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Invest Med. 2017;65:722-725. 54. Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial. JAMA. 2017;317:483-493. This recent study showed no difference in rates of successful first-pass intubation between direct laryngoscopy and video laryngoscopy. 55. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Prac-tice guidelines for management of the difficult airwayan updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesi-ology. 2013;118:251-270. The ASA Difficult Airway Algorithm, last updated in 2013, provides guidelines for management of patients with expected or unexpected difficult airways. 56. Popping DM, Elia N, Marret E, et al. Protective effects of epi-dural analgesia on | Surgery_Schwartz. Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Invest Med. 2017;65:722-725. 54. Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial. JAMA. 2017;317:483-493. This recent study showed no difference in rates of successful first-pass intubation between direct laryngoscopy and video laryngoscopy. 55. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Prac-tice guidelines for management of the difficult airwayan updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesi-ology. 2013;118:251-270. The ASA Difficult Airway Algorithm, last updated in 2013, provides guidelines for management of patients with expected or unexpected difficult airways. 56. Popping DM, Elia N, Marret E, et al. Protective effects of epi-dural analgesia on | [
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Surgery_Schwartz_13340 | Surgery_Schwartz | updated in 2013, provides guidelines for management of patients with expected or unexpected difficult airways. 56. Popping DM, Elia N, Marret E, et al. Protective effects of epi-dural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg. (Chicago, IL 1960). 2008;143:990-999; discussion 1000. 57. Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology. 2011;115:181-188. 58. Bashandy GMN, Elkholy AHH. Reducing postoperative opioid consumption by adding an ultrasound-guided rectus sheath block to multimodal analgesia for abdominal cancer surgery with midline incision. Anesthesiol Pain Med. 2014; 4:e18263. 59. Ris F, Findlay JM, Hompes R, et al. Addition of transversus abdominis plane block to patient controlled analgesia for lapa-roscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function. Ann R Coll Surg Engl. 2014;96:579-585. 60. Palumbo P, | Surgery_Schwartz. updated in 2013, provides guidelines for management of patients with expected or unexpected difficult airways. 56. Popping DM, Elia N, Marret E, et al. Protective effects of epi-dural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg. (Chicago, IL 1960). 2008;143:990-999; discussion 1000. 57. Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology. 2011;115:181-188. 58. Bashandy GMN, Elkholy AHH. Reducing postoperative opioid consumption by adding an ultrasound-guided rectus sheath block to multimodal analgesia for abdominal cancer surgery with midline incision. Anesthesiol Pain Med. 2014; 4:e18263. 59. Ris F, Findlay JM, Hompes R, et al. Addition of transversus abdominis plane block to patient controlled analgesia for lapa-roscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function. Ann R Coll Surg Engl. 2014;96:579-585. 60. Palumbo P, | [
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Surgery_Schwartz_13341 | Surgery_Schwartz | analgesia for lapa-roscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function. Ann R Coll Surg Engl. 2014;96:579-585. 60. Palumbo P, Tellan G, Perotti B, et al. Modified PADSS (post anaesthetic discharge scoring system) for monitoring outpa-tients discharge. Ann Ital Chir. 2013;84:661-665. 61. Phillips NM, Street M, Kent B, et al. Post-anaesthetic discharge scoring criteria: key findings from a systematic review. Int J Evid Based Healthc. 2013;11:275-284. 62. Phillips NM, Haesler E, Street M, et al. Post-anaesthetic dis-charge scoring criteria: a systematic review. JBI Libr Syst Rev. 2011;9:1679-1713. 63. Watcha MF, White PF. Postoperative nausea and vomit-ing. Its etiology, treatment, and prevention. Anesthesiology. 1992;77:162-184. 64. Habib AS, Chen YT, Taguchi A, et al. Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis. Curr Med Res Opin. 2006;22: | Surgery_Schwartz. analgesia for lapa-roscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function. Ann R Coll Surg Engl. 2014;96:579-585. 60. Palumbo P, Tellan G, Perotti B, et al. Modified PADSS (post anaesthetic discharge scoring system) for monitoring outpa-tients discharge. Ann Ital Chir. 2013;84:661-665. 61. Phillips NM, Street M, Kent B, et al. Post-anaesthetic discharge scoring criteria: key findings from a systematic review. Int J Evid Based Healthc. 2013;11:275-284. 62. Phillips NM, Haesler E, Street M, et al. Post-anaesthetic dis-charge scoring criteria: a systematic review. JBI Libr Syst Rev. 2011;9:1679-1713. 63. Watcha MF, White PF. Postoperative nausea and vomit-ing. Its etiology, treatment, and prevention. Anesthesiology. 1992;77:162-184. 64. Habib AS, Chen YT, Taguchi A, et al. Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis. Curr Med Res Opin. 2006;22: | [
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Surgery_Schwartz_13342 | Surgery_Schwartz | AS, Chen YT, Taguchi A, et al. Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis. Curr Med Res Opin. 2006;22: 1093-1099. 65. Eskicioglu C, Forbes SS, Aarts MA, et al. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg. 2009;13:2321-2329. 66. Sammour T, Zargar-Shoshtari K, Bhat A, et al. A programme of enhanced recovery after surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010; 123:61-70. 67. Reurings JC, Spanjersberg WR, Oostvogel HJ, et al. A prospec-tive cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track mul-timodal management, for surgical patients with colon carcinomas (TAPAS study). BMC Surg. 2010;10:18. 68. Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal | Surgery_Schwartz. AS, Chen YT, Taguchi A, et al. Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis. Curr Med Res Opin. 2006;22: 1093-1099. 65. Eskicioglu C, Forbes SS, Aarts MA, et al. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg. 2009;13:2321-2329. 66. Sammour T, Zargar-Shoshtari K, Bhat A, et al. A programme of enhanced recovery after surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010; 123:61-70. 67. Reurings JC, Spanjersberg WR, Oostvogel HJ, et al. A prospec-tive cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track mul-timodal management, for surgical patients with colon carcinomas (TAPAS study). BMC Surg. 2010;10:18. 68. Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal | [
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Surgery_Schwartz_13343 | Surgery_Schwartz | management, for surgical patients with colon carcinomas (TAPAS study). BMC Surg. 2010;10:18. 68. Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115:694-702. 69. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for pro-longed opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251. 70. CDC grand rounds: prescription drug overdoses—a U.S. epi-demic. MMWR Morb Mortal Wkly Rep. 2012;61:10-13. 71. Rosenberg H, Pollock N, Schiemann A, et al. Malignant hyper-thermia: a review. Orphanet J Rare Dis. 2015;10:93. 72. Jaber S, Lescot T, Futier E, et al. Effect of noninvasive ventila-tion on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: a randomized clinical trial. JAMA. 2016;315:1345-1353. 73. Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextu-bation high-flow nasal cannula vs conventional oxygen therapy | Surgery_Schwartz. management, for surgical patients with colon carcinomas (TAPAS study). BMC Surg. 2010;10:18. 68. Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115:694-702. 69. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for pro-longed opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251. 70. CDC grand rounds: prescription drug overdoses—a U.S. epi-demic. MMWR Morb Mortal Wkly Rep. 2012;61:10-13. 71. Rosenberg H, Pollock N, Schiemann A, et al. Malignant hyper-thermia: a review. Orphanet J Rare Dis. 2015;10:93. 72. Jaber S, Lescot T, Futier E, et al. Effect of noninvasive ventila-tion on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: a randomized clinical trial. JAMA. 2016;315:1345-1353. 73. Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextu-bation high-flow nasal cannula vs conventional oxygen therapy | [
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Surgery_Schwartz_13345 | Surgery_Schwartz | FOR SURGICAL PATIENTSCHAPTER 46 76. Parke R, McGuinness S, Dixon R, et al. Open-label, phase II study of routine high-flow nasal oxygen therapy in cardiac sur-gical patients. Br J Anaesth. 2013;111:925-931. 77. Stephan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313:2331-2339. 78. Vijayakumar B, Elango P, Ganessan R. Post-operative delirium in elderly patients. Indian J Anaesth. 2014;58:251-256. 79. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cogni-tive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108:18-30. 80. Crosby G, Culley DJ, Hyman BT. Preoperative cognitive assessment of the elderly surgical patient: a call for action. Anesthesiology. 2011;114:1265-1268.Brunicardi_Ch46_p2027-p2044.indd 204301/03/19 11:04 AM | Surgery_Schwartz. FOR SURGICAL PATIENTSCHAPTER 46 76. Parke R, McGuinness S, Dixon R, et al. Open-label, phase II study of routine high-flow nasal oxygen therapy in cardiac sur-gical patients. Br J Anaesth. 2013;111:925-931. 77. Stephan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313:2331-2339. 78. Vijayakumar B, Elango P, Ganessan R. Post-operative delirium in elderly patients. Indian J Anaesth. 2014;58:251-256. 79. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cogni-tive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108:18-30. 80. Crosby G, Culley DJ, Hyman BT. Preoperative cognitive assessment of the elderly surgical patient: a call for action. Anesthesiology. 2011;114:1265-1268.Brunicardi_Ch46_p2027-p2044.indd 204301/03/19 11:04 AM | [
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Surgery_Schwartz_13347 | Surgery_Schwartz | Surgical Considerations in Older AdultsAnne M. Suskind and Emily Finlayson 47chapterINTRODUCTIONAs the population ages, an increasing number of older adults will develop surgical diseases. The segment of the U.S. popu-lation age 65 and older is expected to double by 2050. Older adults present unique challenges in surgical management and decision-making. The accumulation of comorbid conditions and physiologic vulnerability that occurs with age put older adults at high risk for major morbidity and mortality after sur-gery. It is essential that surgeons approach this population with a new set of skills and knowledge to provide optimal care for this vulnerable population. A comprehensive understanding of the unique vulnerabilities of older adults—geriatric syndromes and risk factors—are required to accurately estimate surgical risk, inform surgical decision-making, and guide perioperative management. In this chapter, we will (a) discuss the physiologic conditions that are common in older | Surgery_Schwartz. Surgical Considerations in Older AdultsAnne M. Suskind and Emily Finlayson 47chapterINTRODUCTIONAs the population ages, an increasing number of older adults will develop surgical diseases. The segment of the U.S. popu-lation age 65 and older is expected to double by 2050. Older adults present unique challenges in surgical management and decision-making. The accumulation of comorbid conditions and physiologic vulnerability that occurs with age put older adults at high risk for major morbidity and mortality after sur-gery. It is essential that surgeons approach this population with a new set of skills and knowledge to provide optimal care for this vulnerable population. A comprehensive understanding of the unique vulnerabilities of older adults—geriatric syndromes and risk factors—are required to accurately estimate surgical risk, inform surgical decision-making, and guide perioperative management. In this chapter, we will (a) discuss the physiologic conditions that are common in older | [
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Surgery_Schwartz_13348 | Surgery_Schwartz | to accurately estimate surgical risk, inform surgical decision-making, and guide perioperative management. In this chapter, we will (a) discuss the physiologic conditions that are common in older adults that are essential for surgical risk assessment of older adults considering surgery, (b) describe best practices in perioperative care in the older adult, and (c) discuss special considerations and common pitfalls for surgical conditions that are common in the older adult.GERIATRIC SYNDROMESApproximately one-third of older individuals undergoing vascu-lar and urologic surgery suffer from geriatric syndromes.1,2 This term is used to describe clinical conditions that do not fit into discrete disease categories but that can substantially negatively impact quality of life and result in disability. Geriat-ric syndromes often involve multiple underlying factors and organ systems (i.e., multiple causation of a unified manifesta-tion3) and include frailty, falls, delirium, malnutrition, | Surgery_Schwartz. to accurately estimate surgical risk, inform surgical decision-making, and guide perioperative management. In this chapter, we will (a) discuss the physiologic conditions that are common in older adults that are essential for surgical risk assessment of older adults considering surgery, (b) describe best practices in perioperative care in the older adult, and (c) discuss special considerations and common pitfalls for surgical conditions that are common in the older adult.GERIATRIC SYNDROMESApproximately one-third of older individuals undergoing vascu-lar and urologic surgery suffer from geriatric syndromes.1,2 This term is used to describe clinical conditions that do not fit into discrete disease categories but that can substantially negatively impact quality of life and result in disability. Geriat-ric syndromes often involve multiple underlying factors and organ systems (i.e., multiple causation of a unified manifesta-tion3) and include frailty, falls, delirium, malnutrition, | [
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] |
Surgery_Schwartz_13349 | Surgery_Schwartz | Geriat-ric syndromes often involve multiple underlying factors and organ systems (i.e., multiple causation of a unified manifesta-tion3) and include frailty, falls, delirium, malnutrition, dizziness, syncope, urinary incontinence, and pressure ulcers among oth-ers. These syndromes can be present before surgery and/or 1develop as a result of surgery and hospitalization.1,2 Further-more, close attention to both the presence and development of geriatric syndromes among surgical candidates is important and often overlooked, making caring for older surgical patients unique compared to their younger and healthier counterparts.FrailtyFrailty is among the most widely studied geriatric syndrome in the surgical literature. Frail older individuals are at high risk for adverse events in the face of stressors such as surgery. They are more likely to experience surgical complications, delayed recovery, falls, and to develop functional impairment. Frailty is also associated with a higher risk of | Surgery_Schwartz. Geriat-ric syndromes often involve multiple underlying factors and organ systems (i.e., multiple causation of a unified manifesta-tion3) and include frailty, falls, delirium, malnutrition, dizziness, syncope, urinary incontinence, and pressure ulcers among oth-ers. These syndromes can be present before surgery and/or 1develop as a result of surgery and hospitalization.1,2 Further-more, close attention to both the presence and development of geriatric syndromes among surgical candidates is important and often overlooked, making caring for older surgical patients unique compared to their younger and healthier counterparts.FrailtyFrailty is among the most widely studied geriatric syndrome in the surgical literature. Frail older individuals are at high risk for adverse events in the face of stressors such as surgery. They are more likely to experience surgical complications, delayed recovery, falls, and to develop functional impairment. Frailty is also associated with a higher risk of | [
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Surgery_Schwartz_13350 | Surgery_Schwartz | stressors such as surgery. They are more likely to experience surgical complications, delayed recovery, falls, and to develop functional impairment. Frailty is also associated with a higher risk of death. It Is believed that frailty is a chronic, progressive condition that represents a spec-trum; less frail individuals may be responsive to strategies or interventions to ameliorate its clinical manifestations, while more frail individuals may demonstrate an irreversible predeath condition with limited life expectancy.4Frailty has been shown to be independently predictive of poor postoperative outcomes. Makary et al studied 594 older patients presenting for elective surgery at a university hospital and demonstrated that frail individuals were at increased risk of postoperative complications (OR 2.54; 95% CI 1.12–5.77), lon-ger length of stay (incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted living facility after previ-ously living at home (OR 20.48; | Surgery_Schwartz. stressors such as surgery. They are more likely to experience surgical complications, delayed recovery, falls, and to develop functional impairment. Frailty is also associated with a higher risk of death. It Is believed that frailty is a chronic, progressive condition that represents a spec-trum; less frail individuals may be responsive to strategies or interventions to ameliorate its clinical manifestations, while more frail individuals may demonstrate an irreversible predeath condition with limited life expectancy.4Frailty has been shown to be independently predictive of poor postoperative outcomes. Makary et al studied 594 older patients presenting for elective surgery at a university hospital and demonstrated that frail individuals were at increased risk of postoperative complications (OR 2.54; 95% CI 1.12–5.77), lon-ger length of stay (incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted living facility after previ-ously living at home (OR 20.48; | [
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Surgery_Schwartz_13351 | Surgery_Schwartz | (OR 2.54; 95% CI 1.12–5.77), lon-ger length of stay (incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted living facility after previ-ously living at home (OR 20.48; 95% CI 5.54-75.68).5 Similar findings have been echoed throughout the surgical literature inclusive of vascular, colorectal, cardiac, urologic, and other types of procedures.6-11Definitions of frailty fall into two broad models; a pheno-typic model and a deficits accumulation model. The phenotypic model was originally described by Linda Fried using data from the Cardiovascular Health Study, which is an observational study of community-dwelling men and women age 65 years and Introduction 2045Geriatric Syndromes 2045Frailty / 2045Falls / 2047Delirium / 2047Preoperative Assessment 2047Best Practices: Preoperative Assessment / 2048Frailty Assessment / 2049Cognitive and Behavioral Assessment / 2049Medical Assessment / 2050Nutritional Assessment / 2051Psychosocial Considerations / 2052Medication | Surgery_Schwartz. (OR 2.54; 95% CI 1.12–5.77), lon-ger length of stay (incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted living facility after previ-ously living at home (OR 20.48; 95% CI 5.54-75.68).5 Similar findings have been echoed throughout the surgical literature inclusive of vascular, colorectal, cardiac, urologic, and other types of procedures.6-11Definitions of frailty fall into two broad models; a pheno-typic model and a deficits accumulation model. The phenotypic model was originally described by Linda Fried using data from the Cardiovascular Health Study, which is an observational study of community-dwelling men and women age 65 years and Introduction 2045Geriatric Syndromes 2045Frailty / 2045Falls / 2047Delirium / 2047Preoperative Assessment 2047Best Practices: Preoperative Assessment / 2048Frailty Assessment / 2049Cognitive and Behavioral Assessment / 2049Medical Assessment / 2050Nutritional Assessment / 2051Psychosocial Considerations / 2052Medication | [
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Surgery_Schwartz_13352 | Surgery_Schwartz | Preoperative Assessment / 2048Frailty Assessment / 2049Cognitive and Behavioral Assessment / 2049Medical Assessment / 2050Nutritional Assessment / 2051Psychosocial Considerations / 2052Medication Review / 2052Patient Counseling / 2052Preoperative Preparation 2052Patient Goals, Preferences, and Advance Directives / 2052Preoperative Fasting / 2053Antibiotic Prophylaxis and Venous Thromboembolism Prevention / 2053Surgical Prehabilitation / 2053Palliative Care Services for Older Surgical Patients / 2053Special Considerations 2054Functional Recovery / 2054Cancer Surgery / 2055Emergency Surgery / 2055Cardiovascular Surgery / 2055Valve Replacement / 2055Endovascular Aortic Surgery / 2056Palliative Surgery / 2056Summary 2056Brunicardi_Ch47_p2045-p2060.indd 204528/02/19 2:08 PM 2046Table 47-1Criteria used to define frailty• Weight loss: “In the last year, have you lost more than 10 pounds unintentionally (i.e., not due to dieting or exercise)?” If yes, then frail for weight loss | Surgery_Schwartz. Preoperative Assessment / 2048Frailty Assessment / 2049Cognitive and Behavioral Assessment / 2049Medical Assessment / 2050Nutritional Assessment / 2051Psychosocial Considerations / 2052Medication Review / 2052Patient Counseling / 2052Preoperative Preparation 2052Patient Goals, Preferences, and Advance Directives / 2052Preoperative Fasting / 2053Antibiotic Prophylaxis and Venous Thromboembolism Prevention / 2053Surgical Prehabilitation / 2053Palliative Care Services for Older Surgical Patients / 2053Special Considerations 2054Functional Recovery / 2054Cancer Surgery / 2055Emergency Surgery / 2055Cardiovascular Surgery / 2055Valve Replacement / 2055Endovascular Aortic Surgery / 2056Palliative Surgery / 2056Summary 2056Brunicardi_Ch47_p2045-p2060.indd 204528/02/19 2:08 PM 2046Table 47-1Criteria used to define frailty• Weight loss: “In the last year, have you lost more than 10 pounds unintentionally (i.e., not due to dieting or exercise)?” If yes, then frail for weight loss | [
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Surgery_Schwartz_13353 | Surgery_Schwartz | 47-1Criteria used to define frailty• Weight loss: “In the last year, have you lost more than 10 pounds unintentionally (i.e., not due to dieting or exercise)?” If yes, then frail for weight loss criterion. At follow-up, weight loss was calculated as: (Weight in previous year – current measured weight)/(weight in previous year) = K. If K ≥0.05 and the subject does not report that he/she was trying to lose weight (i.e., unintentional weight loss of at least 5% of previous year’s body weight), then frail for weight loss = Yes.• Exhaustion: Using the CES-D Depression Scale, the following two statements are read. (a) I felt that everything I did was an effort; (b) I could not get going. The question is asked “How often in the last week did you feel this way?” 0 = rarely or none of the time (<1 day), 1 = some or a little of the time (1–2 days), 2 = a moderate amount of the time (3–4 days), or 3 = most of the time. Subjects answering “2” or “3” to either of these questions are categorized as | Surgery_Schwartz. 47-1Criteria used to define frailty• Weight loss: “In the last year, have you lost more than 10 pounds unintentionally (i.e., not due to dieting or exercise)?” If yes, then frail for weight loss criterion. At follow-up, weight loss was calculated as: (Weight in previous year – current measured weight)/(weight in previous year) = K. If K ≥0.05 and the subject does not report that he/she was trying to lose weight (i.e., unintentional weight loss of at least 5% of previous year’s body weight), then frail for weight loss = Yes.• Exhaustion: Using the CES-D Depression Scale, the following two statements are read. (a) I felt that everything I did was an effort; (b) I could not get going. The question is asked “How often in the last week did you feel this way?” 0 = rarely or none of the time (<1 day), 1 = some or a little of the time (1–2 days), 2 = a moderate amount of the time (3–4 days), or 3 = most of the time. Subjects answering “2” or “3” to either of these questions are categorized as | [
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Surgery_Schwartz_13354 | Surgery_Schwartz | day), 1 = some or a little of the time (1–2 days), 2 = a moderate amount of the time (3–4 days), or 3 = most of the time. Subjects answering “2” or “3” to either of these questions are categorized as frail by the exhaustion criterion.• Physical Activity: Based on the short version of the Minnesota Leisure Time Activity questionnaire, asking about walking, chores (moderately strenuous), mowing the lawn, raking, gardening, hiking, jogging, biking, exercise cycling, dancing, aerobics, bowling, golf, singles tennis, doubles tennis, racquetball, calisthenics, swimming. Kcals per week expended are calculated using standardized algorithm. This variable is stratified by gender. Men: Those with Kcal of physical activity per week <383 are frail. Women: Those with Kcals per week <270 are frail.• Walk Time, stratified by gender and height (gender-specific cutoff a medium height). Men Height ≤173 cm Height >173 cmCutoff for time to walk 15 feet criterion for frailty≥7 seconds≥6 | Surgery_Schwartz. day), 1 = some or a little of the time (1–2 days), 2 = a moderate amount of the time (3–4 days), or 3 = most of the time. Subjects answering “2” or “3” to either of these questions are categorized as frail by the exhaustion criterion.• Physical Activity: Based on the short version of the Minnesota Leisure Time Activity questionnaire, asking about walking, chores (moderately strenuous), mowing the lawn, raking, gardening, hiking, jogging, biking, exercise cycling, dancing, aerobics, bowling, golf, singles tennis, doubles tennis, racquetball, calisthenics, swimming. Kcals per week expended are calculated using standardized algorithm. This variable is stratified by gender. Men: Those with Kcal of physical activity per week <383 are frail. Women: Those with Kcals per week <270 are frail.• Walk Time, stratified by gender and height (gender-specific cutoff a medium height). Men Height ≤173 cm Height >173 cmCutoff for time to walk 15 feet criterion for frailty≥7 seconds≥6 | [
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Surgery_Schwartz_13355 | Surgery_Schwartz | are frail.• Walk Time, stratified by gender and height (gender-specific cutoff a medium height). Men Height ≤173 cm Height >173 cmCutoff for time to walk 15 feet criterion for frailty≥7 seconds≥6 seconds Women Height ≤159 cm Height >159 cm≥7 seconds≥6 seconds• Grip Strength, stratified by gender and body mass index (BMI) quartiles: Men BMI ≤24 BMI 24.1–26 BMI 26.1–28 BMI >28Cutoff for grip strength (Kg) criterion for frailty≤29≤30≤30≤32 Women BMI ≤23 BMI 23.1–26 BMI 26.1–29 BMI >29≤17≤17.3≤18≤21Reproduced with permission from Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-M156.older. Individuals in this cohort underwent baseline evaluations and had 4 to 7 years of follow-up with annual examinations and surveillance for the following outcomes: incident disease, hos-pitalization, falls, disability, and mortality. Based on observa-tions in these individuals over time, the following criteria were | Surgery_Schwartz. are frail.• Walk Time, stratified by gender and height (gender-specific cutoff a medium height). Men Height ≤173 cm Height >173 cmCutoff for time to walk 15 feet criterion for frailty≥7 seconds≥6 seconds Women Height ≤159 cm Height >159 cm≥7 seconds≥6 seconds• Grip Strength, stratified by gender and body mass index (BMI) quartiles: Men BMI ≤24 BMI 24.1–26 BMI 26.1–28 BMI >28Cutoff for grip strength (Kg) criterion for frailty≤29≤30≤30≤32 Women BMI ≤23 BMI 23.1–26 BMI 26.1–29 BMI >29≤17≤17.3≤18≤21Reproduced with permission from Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-M156.older. Individuals in this cohort underwent baseline evaluations and had 4 to 7 years of follow-up with annual examinations and surveillance for the following outcomes: incident disease, hos-pitalization, falls, disability, and mortality. Based on observa-tions in these individuals over time, the following criteria were | [
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Surgery_Schwartz_13356 | Surgery_Schwartz | and surveillance for the following outcomes: incident disease, hos-pitalization, falls, disability, and mortality. Based on observa-tions in these individuals over time, the following criteria were identified to define frailty: weight loss, exhaustion, physical activity, walk time, and grip strength (Table 47-1). The pres-ence of one or two of these factors is associated with intermedi-ate risk for poor outcomes, i.e., a “prefrail” phenotype, and the presence of three or more of these factors is associated with high risk for poor outcomes, i.e., a “frail” phenotype.12 This study additionally demonstrated that frailty is strongly associated Key Points1 Frailty, dementia, and functional impairment are significant contributors to morbidity and mortality after surgery. Assess-ment of these risk factors is essential in an older population.2 Geriatric perioperative pathways are effective in preventing delirium, a morbid and costly postoperative complication that is associated with cognitive | Surgery_Schwartz. and surveillance for the following outcomes: incident disease, hos-pitalization, falls, disability, and mortality. Based on observa-tions in these individuals over time, the following criteria were identified to define frailty: weight loss, exhaustion, physical activity, walk time, and grip strength (Table 47-1). The pres-ence of one or two of these factors is associated with intermedi-ate risk for poor outcomes, i.e., a “prefrail” phenotype, and the presence of three or more of these factors is associated with high risk for poor outcomes, i.e., a “frail” phenotype.12 This study additionally demonstrated that frailty is strongly associated Key Points1 Frailty, dementia, and functional impairment are significant contributors to morbidity and mortality after surgery. Assess-ment of these risk factors is essential in an older population.2 Geriatric perioperative pathways are effective in preventing delirium, a morbid and costly postoperative complication that is associated with cognitive | [
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Surgery_Schwartz_13357 | Surgery_Schwartz | factors is essential in an older population.2 Geriatric perioperative pathways are effective in preventing delirium, a morbid and costly postoperative complication that is associated with cognitive decline.3 Population-based data demonstrate that mortality after emer-gency surgery and high-risk cancer surgery is substantially higher in older adults that in a younger population.4 Impaired cardiac function is responsible for more than half of the postoperative deaths in older adult patients, so careful attention must be paid to intravascular volume status in the perioperative period.5 Many frail elders experience significant and sustained func-tional decline after surgery.6 Older adults with acute abdominal pathology—appendicitis, cholecystitis—often do not have fever, elevated white blood cell count, or physical findings of peritonitis.Brunicardi_Ch47_p2045-p2060.indd 204628/02/19 2:08 PM 2047SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47with several major chronic diseases, | Surgery_Schwartz. factors is essential in an older population.2 Geriatric perioperative pathways are effective in preventing delirium, a morbid and costly postoperative complication that is associated with cognitive decline.3 Population-based data demonstrate that mortality after emer-gency surgery and high-risk cancer surgery is substantially higher in older adults that in a younger population.4 Impaired cardiac function is responsible for more than half of the postoperative deaths in older adult patients, so careful attention must be paid to intravascular volume status in the perioperative period.5 Many frail elders experience significant and sustained func-tional decline after surgery.6 Older adults with acute abdominal pathology—appendicitis, cholecystitis—often do not have fever, elevated white blood cell count, or physical findings of peritonitis.Brunicardi_Ch47_p2045-p2060.indd 204628/02/19 2:08 PM 2047SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47with several major chronic diseases, | [
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Surgery_Schwartz_13358 | Surgery_Schwartz | cell count, or physical findings of peritonitis.Brunicardi_Ch47_p2045-p2060.indd 204628/02/19 2:08 PM 2047SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47with several major chronic diseases, including cardiovascular disease, pulmonary disease, and diabetes; however, not all frail individuals demonstrated these associations. The same is true for disability. While there is some overlap between frailty and disability, not all frail individuals are disabled. These findings suggest that while there may be overlap between these three constructs in some individuals, frailty is a distinct process from both comorbidity and disability.12Alternatively, the deficit accumulation model, developed by Rockwood et al, suggests that frailty is defined by discrete failures of redundant physiologic systems. The more deficits that occur, the more likely it is that adverse outcomes will result. Using data from the Canadian Study of Health and Aging, a longitudinal study of individuals age 65 and | Surgery_Schwartz. cell count, or physical findings of peritonitis.Brunicardi_Ch47_p2045-p2060.indd 204628/02/19 2:08 PM 2047SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47with several major chronic diseases, including cardiovascular disease, pulmonary disease, and diabetes; however, not all frail individuals demonstrated these associations. The same is true for disability. While there is some overlap between frailty and disability, not all frail individuals are disabled. These findings suggest that while there may be overlap between these three constructs in some individuals, frailty is a distinct process from both comorbidity and disability.12Alternatively, the deficit accumulation model, developed by Rockwood et al, suggests that frailty is defined by discrete failures of redundant physiologic systems. The more deficits that occur, the more likely it is that adverse outcomes will result. Using data from the Canadian Study of Health and Aging, a longitudinal study of individuals age 65 and | [
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Surgery_Schwartz_13359 | Surgery_Schwartz | systems. The more deficits that occur, the more likely it is that adverse outcomes will result. Using data from the Canadian Study of Health and Aging, a longitudinal study of individuals age 65 and older, the authors developed a frailty index represented by the cumulative pro-portion of 92 accumulated deficits, which include symptoms, signs, functional impairments, and laboratory abnormalities. They demonstrated that deficits accumulated at a rate of 3% per year in their cohort, represented a gamma distribution, and increased with chronological age; they proposed that this model be used as a proxy for aging and mortality.13While these models are helpful to conceptualize frailty, no one model is all inclusive, and each may have applicability in different settings. For example, the frailty phenotype does not include items on cognition or mood and may not be easily appli-cable to the busy clinical setting.14 The deficits accumulation model is ideal for use in large databases, such as | Surgery_Schwartz. systems. The more deficits that occur, the more likely it is that adverse outcomes will result. Using data from the Canadian Study of Health and Aging, a longitudinal study of individuals age 65 and older, the authors developed a frailty index represented by the cumulative pro-portion of 92 accumulated deficits, which include symptoms, signs, functional impairments, and laboratory abnormalities. They demonstrated that deficits accumulated at a rate of 3% per year in their cohort, represented a gamma distribution, and increased with chronological age; they proposed that this model be used as a proxy for aging and mortality.13While these models are helpful to conceptualize frailty, no one model is all inclusive, and each may have applicability in different settings. For example, the frailty phenotype does not include items on cognition or mood and may not be easily appli-cable to the busy clinical setting.14 The deficits accumulation model is ideal for use in large databases, such as | [
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Surgery_Schwartz_13360 | Surgery_Schwartz | phenotype does not include items on cognition or mood and may not be easily appli-cable to the busy clinical setting.14 The deficits accumulation model is ideal for use in large databases, such as the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP),15 and may be helpful for research and public health and policy purposes, but it is not practical for clini-cal care. Measurement of frailty in the clinical setting will be discussed later in this chapter.While frailty is often defined as a geriatric syndrome, it is also plausible that other geriatric syndromes (i.e., urinary incontinence, falls, pressure ulcers, delirium, and functional decline) may demonstrate shared risk factors that lead to frailty. In turn, frailty may also cause more risk factors and more geriat-ric syndromes.16 Regardless of the association and directionality between frailty and other geriatric syndromes, identification of each is essential in the preoperative setting in order | Surgery_Schwartz. phenotype does not include items on cognition or mood and may not be easily appli-cable to the busy clinical setting.14 The deficits accumulation model is ideal for use in large databases, such as the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP),15 and may be helpful for research and public health and policy purposes, but it is not practical for clini-cal care. Measurement of frailty in the clinical setting will be discussed later in this chapter.While frailty is often defined as a geriatric syndrome, it is also plausible that other geriatric syndromes (i.e., urinary incontinence, falls, pressure ulcers, delirium, and functional decline) may demonstrate shared risk factors that lead to frailty. In turn, frailty may also cause more risk factors and more geriat-ric syndromes.16 Regardless of the association and directionality between frailty and other geriatric syndromes, identification of each is essential in the preoperative setting in order | [
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Surgery_Schwartz_13361 | Surgery_Schwartz | more geriat-ric syndromes.16 Regardless of the association and directionality between frailty and other geriatric syndromes, identification of each is essential in the preoperative setting in order to help risk stratify and potentially to mitigate risk for patients considering surgical intervention.FallsOlder adults are at markedly increased risk of falls, and one in three adults age 65 and older report falling in the last year. The incidence of falls increases with age, and close to 60% of individuals who have fallen in the last year will fall again within the following year. Falls are associated with subsequent declines in functional status, greater likelihood of nursing home placement, increased use of medical services, and development of a fear of falling. Approx-imately half of older individuals who fall are unable to get up, resulting in a “long lie,” which is further associated with lasting functional declines.17 In fact, falls can be so detrimental to older individuals that | Surgery_Schwartz. more geriat-ric syndromes.16 Regardless of the association and directionality between frailty and other geriatric syndromes, identification of each is essential in the preoperative setting in order to help risk stratify and potentially to mitigate risk for patients considering surgical intervention.FallsOlder adults are at markedly increased risk of falls, and one in three adults age 65 and older report falling in the last year. The incidence of falls increases with age, and close to 60% of individuals who have fallen in the last year will fall again within the following year. Falls are associated with subsequent declines in functional status, greater likelihood of nursing home placement, increased use of medical services, and development of a fear of falling. Approx-imately half of older individuals who fall are unable to get up, resulting in a “long lie,” which is further associated with lasting functional declines.17 In fact, falls can be so detrimental to older individuals that | [
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Surgery_Schwartz_13362 | Surgery_Schwartz | individuals who fall are unable to get up, resulting in a “long lie,” which is further associated with lasting functional declines.17 In fact, falls can be so detrimental to older individuals that the Joint Commission (United States) established fall prevention as one of its national safety goals in 2015.18Causes of falls can be multifactorial, as with other geri-atric syndromes. Factors include age-related declines, chronic disease, medications, environmental factors, changing positions, routine activities, risk-taking behaviors, acute illness, or situ-ational hazards such as the unfamiliar setting of hospitals and long-term care facilities.17It has been shown that preoperative falls are associated with poor postoperative outcomes among patients undergoing elective surgery. One study looking at 7982 such patients found that a preoperative history of one, two, or three or more falls predicted postoperative falls at 30 days (adjusted OR 2.3, 3.6, 5.5, respectively) and 1 year (adjusted | Surgery_Schwartz. individuals who fall are unable to get up, resulting in a “long lie,” which is further associated with lasting functional declines.17 In fact, falls can be so detrimental to older individuals that the Joint Commission (United States) established fall prevention as one of its national safety goals in 2015.18Causes of falls can be multifactorial, as with other geri-atric syndromes. Factors include age-related declines, chronic disease, medications, environmental factors, changing positions, routine activities, risk-taking behaviors, acute illness, or situ-ational hazards such as the unfamiliar setting of hospitals and long-term care facilities.17It has been shown that preoperative falls are associated with poor postoperative outcomes among patients undergoing elective surgery. One study looking at 7982 such patients found that a preoperative history of one, two, or three or more falls predicted postoperative falls at 30 days (adjusted OR 2.3, 3.6, 5.5, respectively) and 1 year (adjusted | [
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Surgery_Schwartz_13363 | Surgery_Schwartz | at 7982 such patients found that a preoperative history of one, two, or three or more falls predicted postoperative falls at 30 days (adjusted OR 2.3, 3.6, 5.5, respectively) and 1 year (adjusted OR 2.3, 3.4, 6.9, respec-tively), in addition to predicting a decline in functional status at 30 days (adjusted OR 1.2, 2.4, 2.4, respectively) and 1 year (adjusted OR 1.3, 1.5, 3.2, respectively) and in-hospital compli-cations (adjusted OR 1.2, 1.3, 2.0, respectively).18 Furthermore, preoperative falls are a major predictor of poor postoperative outcomes and may be a valuable preoperative assessment tool as part of routine preoperative care.DeliriumDelirium is a disorder of attention and awareness that develops acutely and tends to fluctuate, as defined by the new Diagnos-tic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Delirium is so common among older adults that up to one third of patients age 70 and older admitted to the hospital experiences delirium, half | Surgery_Schwartz. at 7982 such patients found that a preoperative history of one, two, or three or more falls predicted postoperative falls at 30 days (adjusted OR 2.3, 3.6, 5.5, respectively) and 1 year (adjusted OR 2.3, 3.4, 6.9, respec-tively), in addition to predicting a decline in functional status at 30 days (adjusted OR 1.2, 2.4, 2.4, respectively) and 1 year (adjusted OR 1.3, 1.5, 3.2, respectively) and in-hospital compli-cations (adjusted OR 1.2, 1.3, 2.0, respectively).18 Furthermore, preoperative falls are a major predictor of poor postoperative outcomes and may be a valuable preoperative assessment tool as part of routine preoperative care.DeliriumDelirium is a disorder of attention and awareness that develops acutely and tends to fluctuate, as defined by the new Diagnos-tic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Delirium is so common among older adults that up to one third of patients age 70 and older admitted to the hospital experiences delirium, half | [
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Surgery_Schwartz_13364 | Surgery_Schwartz | of Mental Disorders, Fifth Edition (DSM-5) criteria. Delirium is so common among older adults that up to one third of patients age 70 and older admitted to the hospital experiences delirium, half of which have delirium on admission and the other half of which develop delirium dur-ing the hospitalization itself.19 Rates of delirium among older patients undergoing surgery ranges from 4% to 5% in cataract and urologic procedures to 50% to 60% in infrarenal AAA repair or hip fracture surgery.20 Patients who develop postopera-tive delirium have a twoto threefold increased risk of mortality within the first year after surgery.21Preoperative assessment should focus on the identifi-cation of risk factors for delirium including age 70 years or older, cognitive impairment, limited physical function, history of alcohol abuse, abnormal serum sodium, potassium or glu-cose, intrathoracic surgery, and AAA surgery. Preoperative assessment and documentation of mental status is imperative in order to | Surgery_Schwartz. of Mental Disorders, Fifth Edition (DSM-5) criteria. Delirium is so common among older adults that up to one third of patients age 70 and older admitted to the hospital experiences delirium, half of which have delirium on admission and the other half of which develop delirium dur-ing the hospitalization itself.19 Rates of delirium among older patients undergoing surgery ranges from 4% to 5% in cataract and urologic procedures to 50% to 60% in infrarenal AAA repair or hip fracture surgery.20 Patients who develop postopera-tive delirium have a twoto threefold increased risk of mortality within the first year after surgery.21Preoperative assessment should focus on the identifi-cation of risk factors for delirium including age 70 years or older, cognitive impairment, limited physical function, history of alcohol abuse, abnormal serum sodium, potassium or glu-cose, intrathoracic surgery, and AAA surgery. Preoperative assessment and documentation of mental status is imperative in order to | [
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Surgery_Schwartz_13365 | Surgery_Schwartz | history of alcohol abuse, abnormal serum sodium, potassium or glu-cose, intrathoracic surgery, and AAA surgery. Preoperative assessment and documentation of mental status is imperative in order to establish a baseline for postoperative comparison. Intraoperative blood loss is another risk factor for postopera-tive delirium, and patients with a postoperative hematocrit less than 30% are at increased risk, irrespective of baseline risk fac-tors. Postoperatively, undertreatment of pain is an important risk factor for delirium. Management of fluid, electrolyte and metabolic abnormalities, optimization of blood loss replace-ment, maintenance of circadian rhythms, and cautious prescrip-tion of medication and pain management are among the most important methods by which to minimize the risk of postop-erative delirium among surgical patients.20 Furthermore, many commonly used medications may induce delirium and should be avoided. They include drugs with anticholinergic properties, | Surgery_Schwartz. history of alcohol abuse, abnormal serum sodium, potassium or glu-cose, intrathoracic surgery, and AAA surgery. Preoperative assessment and documentation of mental status is imperative in order to establish a baseline for postoperative comparison. Intraoperative blood loss is another risk factor for postopera-tive delirium, and patients with a postoperative hematocrit less than 30% are at increased risk, irrespective of baseline risk fac-tors. Postoperatively, undertreatment of pain is an important risk factor for delirium. Management of fluid, electrolyte and metabolic abnormalities, optimization of blood loss replace-ment, maintenance of circadian rhythms, and cautious prescrip-tion of medication and pain management are among the most important methods by which to minimize the risk of postop-erative delirium among surgical patients.20 Furthermore, many commonly used medications may induce delirium and should be avoided. They include drugs with anticholinergic properties, | [
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Surgery_Schwartz_13366 | Surgery_Schwartz | risk of postop-erative delirium among surgical patients.20 Furthermore, many commonly used medications may induce delirium and should be avoided. They include drugs with anticholinergic properties, corticosteroids, merperidine, and sedative hypnotics. Finally, postoperative care bundles have been shown to successfully reduce the incidence of delirium. These strategies include sensory enhancement (glasses, hearing aids), early mobility, cognitive orientation and therapeutic activities, and sleep proto-cols. Treatment of postoperative delirium should focus on treat-able etiologies (Fig. 47-1), and pharmacologic treatment should be reserved for patients who are at risk of harming themselves or others.PREOPERATIVE ASSESSMENTPreoperative assessment in older adults is more complex than in younger individuals, as there are many unique characteris-tics that require consideration. The purpose of the assessment Brunicardi_Ch47_p2045-p2060.indd 204728/02/19 2:08 PM 2048SPECIFIC | Surgery_Schwartz. risk of postop-erative delirium among surgical patients.20 Furthermore, many commonly used medications may induce delirium and should be avoided. They include drugs with anticholinergic properties, corticosteroids, merperidine, and sedative hypnotics. Finally, postoperative care bundles have been shown to successfully reduce the incidence of delirium. These strategies include sensory enhancement (glasses, hearing aids), early mobility, cognitive orientation and therapeutic activities, and sleep proto-cols. Treatment of postoperative delirium should focus on treat-able etiologies (Fig. 47-1), and pharmacologic treatment should be reserved for patients who are at risk of harming themselves or others.PREOPERATIVE ASSESSMENTPreoperative assessment in older adults is more complex than in younger individuals, as there are many unique characteris-tics that require consideration. The purpose of the assessment Brunicardi_Ch47_p2045-p2060.indd 204728/02/19 2:08 PM 2048SPECIFIC | [
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Surgery_Schwartz_13367 | Surgery_Schwartz | than in younger individuals, as there are many unique characteris-tics that require consideration. The purpose of the assessment Brunicardi_Ch47_p2045-p2060.indd 204728/02/19 2:08 PM 2048SPECIFIC CONSIDERATIONSPART IIFigure 47-1. Useful algorithm to determine preoperative management of the acutely delirious patient.is not to “clear” the patient for surgery but rather to minimize risks and optimize good outcomes. The ACS NSQIP and the American Geriatrics Society (AGS) published best practice guidelines to help optimize this process. Preoperative planning should be pro-active, commencing at the time of surgical decision-making, if not sooner. To this end, the ACS NSQIP/AGS produced best practice guidelines and a preoperative management checklist to provide a framework for thinking about critical issues in this patient population (Table 47-2).22 In addition to these issues, they emphasize the importance of planning analgesia strategies, making efforts to minimize opioid use and to | Surgery_Schwartz. than in younger individuals, as there are many unique characteris-tics that require consideration. The purpose of the assessment Brunicardi_Ch47_p2045-p2060.indd 204728/02/19 2:08 PM 2048SPECIFIC CONSIDERATIONSPART IIFigure 47-1. Useful algorithm to determine preoperative management of the acutely delirious patient.is not to “clear” the patient for surgery but rather to minimize risks and optimize good outcomes. The ACS NSQIP and the American Geriatrics Society (AGS) published best practice guidelines to help optimize this process. Preoperative planning should be pro-active, commencing at the time of surgical decision-making, if not sooner. To this end, the ACS NSQIP/AGS produced best practice guidelines and a preoperative management checklist to provide a framework for thinking about critical issues in this patient population (Table 47-2).22 In addition to these issues, they emphasize the importance of planning analgesia strategies, making efforts to minimize opioid use and to | [
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Surgery_Schwartz_13368 | Surgery_Schwartz | critical issues in this patient population (Table 47-2).22 In addition to these issues, they emphasize the importance of planning analgesia strategies, making efforts to minimize opioid use and to prevent functional and cognitive decline, obtaining multidisciplinary consultation early and early involvement of allied health staff (i.e., physical or occupational therapy), and anticipating home health needs that may be required at discharge.23Best Practices: Preoperative AssessmentFunctional Assessment. As previously discussed, poor phys-ical function prior to surgery is associated with higher risk of major postoperative complications, increased need for intensive WORKUPPhysical exam• Check surgical wound• Check for tubes/lines/drains• Urinalysis• CBC, BMP• May consider: TSH, NH3, LFT, EtoH/tox• Blood/sputum/urine cultures-Vital signs, pulse ox, pain assessmentMedication reviewLaboratory evaluation:---Chest XRSubstance abuse history--PHARMACOLOGIC MANAGEMENT:ONLY FOR AGITATED DELIRIUM | Surgery_Schwartz. critical issues in this patient population (Table 47-2).22 In addition to these issues, they emphasize the importance of planning analgesia strategies, making efforts to minimize opioid use and to prevent functional and cognitive decline, obtaining multidisciplinary consultation early and early involvement of allied health staff (i.e., physical or occupational therapy), and anticipating home health needs that may be required at discharge.23Best Practices: Preoperative AssessmentFunctional Assessment. As previously discussed, poor phys-ical function prior to surgery is associated with higher risk of major postoperative complications, increased need for intensive WORKUPPhysical exam• Check surgical wound• Check for tubes/lines/drains• Urinalysis• CBC, BMP• May consider: TSH, NH3, LFT, EtoH/tox• Blood/sputum/urine cultures-Vital signs, pulse ox, pain assessmentMedication reviewLaboratory evaluation:---Chest XRSubstance abuse history--PHARMACOLOGIC MANAGEMENT:ONLY FOR AGITATED DELIRIUM | [
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Surgery_Schwartz_13369 | Surgery_Schwartz | Blood/sputum/urine cultures-Vital signs, pulse ox, pain assessmentMedication reviewLaboratory evaluation:---Chest XRSubstance abuse history--PHARMACOLOGIC MANAGEMENT:ONLY FOR AGITATED DELIRIUM AND PATIENT SAFETYAgent of choice: Low dose Haloperidol0.5 mg PO: 1–2 hours for effect, may redose in 60 m0.5 mg IM/IV: 20–40 min to take effect, may redosein 30 mMost patients respond to total of 1–2 mgCheck 12 lead EKG, hold if QTc >500----Use benzos only if there is a concern for withdrawalDIFFERENTIAL DIAGNOSIS DRUG!!! Electrolytes, environment change Lack of drugs (withdrawal), lack of sleep Infection, idiopathic Restraints, reduced sensory input (vision/hearing) Intracranial (CVA, bleed, post-ictal, meningitis) Urinary retention, or fecal impaction Metabolic, includes PE/MI, uremia, ammonia, thyroidDELIRIUMAlways check the medication list – there is acumulative effect burden, any new medicationor recent dose change is suspectAlgorithm for the acutelydelirious patient.For prevention in at | Surgery_Schwartz. Blood/sputum/urine cultures-Vital signs, pulse ox, pain assessmentMedication reviewLaboratory evaluation:---Chest XRSubstance abuse history--PHARMACOLOGIC MANAGEMENT:ONLY FOR AGITATED DELIRIUM AND PATIENT SAFETYAgent of choice: Low dose Haloperidol0.5 mg PO: 1–2 hours for effect, may redose in 60 m0.5 mg IM/IV: 20–40 min to take effect, may redosein 30 mMost patients respond to total of 1–2 mgCheck 12 lead EKG, hold if QTc >500----Use benzos only if there is a concern for withdrawalDIFFERENTIAL DIAGNOSIS DRUG!!! Electrolytes, environment change Lack of drugs (withdrawal), lack of sleep Infection, idiopathic Restraints, reduced sensory input (vision/hearing) Intracranial (CVA, bleed, post-ictal, meningitis) Urinary retention, or fecal impaction Metabolic, includes PE/MI, uremia, ammonia, thyroidDELIRIUMAlways check the medication list – there is acumulative effect burden, any new medicationor recent dose change is suspectAlgorithm for the acutelydelirious patient.For prevention in at | [
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Surgery_Schwartz_13370 | Surgery_Schwartz | thyroidDELIRIUMAlways check the medication list – there is acumulative effect burden, any new medicationor recent dose change is suspectAlgorithm for the acutelydelirious patient.For prevention in at risk patientsplease refer to opposite side.Why are they delirious?Common Delirium Inducing MedicationsRisk FactorsPrecipitating Factors, in aaddition to SURGERYPhysical restraintsMalnutrition3 medication classes addedBladder catheterUncontrolled pain-----PREVENTION/CONSERVATIVE MANAGEMENTSensory enhancement: Hearing aids, glasses at bedsideMobilizationCognitive orientation and stimulationSleep enhancementMedication reviewNormalize environment• Get rid of tethers• Keep room calm and quiet• Encourage family/caregiver involvement------Address/remove precipitating factors or agentsIf MB consider hospitalist consult--Are they a danger tothemselves or others?Age >65Cognitive impairmentComorbidity burdenPoor functional statusHearing/vision impairmentDepression------Anticholinergics: Tricyclics, | Surgery_Schwartz. thyroidDELIRIUMAlways check the medication list – there is acumulative effect burden, any new medicationor recent dose change is suspectAlgorithm for the acutelydelirious patient.For prevention in at risk patientsplease refer to opposite side.Why are they delirious?Common Delirium Inducing MedicationsRisk FactorsPrecipitating Factors, in aaddition to SURGERYPhysical restraintsMalnutrition3 medication classes addedBladder catheterUncontrolled pain-----PREVENTION/CONSERVATIVE MANAGEMENTSensory enhancement: Hearing aids, glasses at bedsideMobilizationCognitive orientation and stimulationSleep enhancementMedication reviewNormalize environment• Get rid of tethers• Keep room calm and quiet• Encourage family/caregiver involvement------Address/remove precipitating factors or agentsIf MB consider hospitalist consult--Are they a danger tothemselves or others?Age >65Cognitive impairmentComorbidity burdenPoor functional statusHearing/vision impairmentDepression------Anticholinergics: Tricyclics, | [
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Surgery_Schwartz_13371 | Surgery_Schwartz | hospitalist consult--Are they a danger tothemselves or others?Age >65Cognitive impairmentComorbidity burdenPoor functional statusHearing/vision impairmentDepression------Anticholinergics: Tricyclics, antihistamines,H2-blockers, antimuscarinics, antispasmodics,promethazine, olanzapine, paroxetineCorticosteroids: methylprednisone, prednisoneMeperidineSedative hypnotics: benzos, zolpidem----Nu-DESC Screen: ScoreEach item scored 0–2• Disorientation• Inappropriate behavior• Inappropriate communication• Illusions/hallucinations• Psychomotor retardationIs your patient acutely delirious?Yes?Differential and workupBrunicardi_Ch47_p2045-p2060.indd 204828/02/19 2:08 PM 2049SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Table 47-2Immediate preoperative management checklist from the ACS NSQIP/AGS1. Confirm and document patient goals and treatment preferences, including advance directives2. Confirm and document patient’s health care proxy or surrogate decision-maker3. In patients with | Surgery_Schwartz. hospitalist consult--Are they a danger tothemselves or others?Age >65Cognitive impairmentComorbidity burdenPoor functional statusHearing/vision impairmentDepression------Anticholinergics: Tricyclics, antihistamines,H2-blockers, antimuscarinics, antispasmodics,promethazine, olanzapine, paroxetineCorticosteroids: methylprednisone, prednisoneMeperidineSedative hypnotics: benzos, zolpidem----Nu-DESC Screen: ScoreEach item scored 0–2• Disorientation• Inappropriate behavior• Inappropriate communication• Illusions/hallucinations• Psychomotor retardationIs your patient acutely delirious?Yes?Differential and workupBrunicardi_Ch47_p2045-p2060.indd 204828/02/19 2:08 PM 2049SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Table 47-2Immediate preoperative management checklist from the ACS NSQIP/AGS1. Confirm and document patient goals and treatment preferences, including advance directives2. Confirm and document patient’s health care proxy or surrogate decision-maker3. In patients with | [
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Surgery_Schwartz_13372 | Surgery_Schwartz | and document patient goals and treatment preferences, including advance directives2. Confirm and document patient’s health care proxy or surrogate decision-maker3. In patients with existing advance directives, discuss new risks associated with the surgical procedure and an approach for potentially life-threatening problems consistent with the patient’s values and preferences4. Consider shortened fluid fast (clear liquids up to two hours before anesthesia)5. Adhere to existing best practices regarding antibiotic and venous thromboembolism prophylaxis6. Ensure nonessential medications have been stopped and essential medications have been takenAdapted with permission from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.rehabilitation services, increased rates of discharge to a skilled or | Surgery_Schwartz. and document patient goals and treatment preferences, including advance directives2. Confirm and document patient’s health care proxy or surrogate decision-maker3. In patients with existing advance directives, discuss new risks associated with the surgical procedure and an approach for potentially life-threatening problems consistent with the patient’s values and preferences4. Consider shortened fluid fast (clear liquids up to two hours before anesthesia)5. Adhere to existing best practices regarding antibiotic and venous thromboembolism prophylaxis6. Ensure nonessential medications have been stopped and essential medications have been takenAdapted with permission from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.rehabilitation services, increased rates of discharge to a skilled or | [
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Surgery_Schwartz_13373 | Surgery_Schwartz | from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.rehabilitation services, increased rates of discharge to a skilled or assisted nursing facility, and higher mortality.24-26 Assessment of physical function and performance status in the preoperative setting are recommended by the ACS NSQIP/AGS best practice guidelines.22 There are several methods by which to measure physical function. Overall functional status may be ascertained by assessing the ability of an individual to perform activities of daily living (ADLs) and instrumental ADLs. ADLs include dressing, bathing, toileting, transferring, continence, and eating independently.25 Instrumental ADLs measure an individual’s ability to live independently and include the ability to perform the following tasks: shopping, laundry, mode of transportation, ability to handle finances, responsibility for won medications, food preparation, and housekeeping.27In addition to | Surgery_Schwartz. from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.rehabilitation services, increased rates of discharge to a skilled or assisted nursing facility, and higher mortality.24-26 Assessment of physical function and performance status in the preoperative setting are recommended by the ACS NSQIP/AGS best practice guidelines.22 There are several methods by which to measure physical function. Overall functional status may be ascertained by assessing the ability of an individual to perform activities of daily living (ADLs) and instrumental ADLs. ADLs include dressing, bathing, toileting, transferring, continence, and eating independently.25 Instrumental ADLs measure an individual’s ability to live independently and include the ability to perform the following tasks: shopping, laundry, mode of transportation, ability to handle finances, responsibility for won medications, food preparation, and housekeeping.27In addition to | [
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Surgery_Schwartz_13374 | Surgery_Schwartz | ability to perform the following tasks: shopping, laundry, mode of transportation, ability to handle finances, responsibility for won medications, food preparation, and housekeeping.27In addition to assessment of ADLs and instrumental ADLs, the surgeon should also assess for deficits in vision, hearing, and swallowing, inquire about history of falls in the past year, evaluate for limitations in gait and mobility, and determine risk for falls, which can be performed via the timed up and go test (TUGT). This test measures gait and mobility impairment and is associated with increased risk for falls in ambulatory individu-als. All that is required to perform this test are a chair, a mark 10 feet in front of the chair, and a stopwatch. Individuals are instructed to do the following while being timed:1. Stand up from the chair (without using arm rests, if possible)2. Walk to the mark (10 feet in front of them)3. Turn4. Walk back to the chair5. Sit down in the chairA time of ≥15 seconds | Surgery_Schwartz. ability to perform the following tasks: shopping, laundry, mode of transportation, ability to handle finances, responsibility for won medications, food preparation, and housekeeping.27In addition to assessment of ADLs and instrumental ADLs, the surgeon should also assess for deficits in vision, hearing, and swallowing, inquire about history of falls in the past year, evaluate for limitations in gait and mobility, and determine risk for falls, which can be performed via the timed up and go test (TUGT). This test measures gait and mobility impairment and is associated with increased risk for falls in ambulatory individu-als. All that is required to perform this test are a chair, a mark 10 feet in front of the chair, and a stopwatch. Individuals are instructed to do the following while being timed:1. Stand up from the chair (without using arm rests, if possible)2. Walk to the mark (10 feet in front of them)3. Turn4. Walk back to the chair5. Sit down in the chairA time of ≥15 seconds | [
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Surgery_Schwartz_13375 | Surgery_Schwartz | timed:1. Stand up from the chair (without using arm rests, if possible)2. Walk to the mark (10 feet in front of them)3. Turn4. Walk back to the chair5. Sit down in the chairA time of ≥15 seconds indicates high risk of falls and should prompt referral to physical therapy for further assessment.In a prospective cohort of individuals age 65 and older undergoing surgery, the TUGT times were stratified into three groups that strongly correlated with varying risk for postop-erative complications and 1-year mortality. These groups were “slow” (≥15 seconds), “intermediate” (11–14 seconds), and “fast” (≤10 seconds). Postoperative complications and 1-year mortality in the slow group were significantly higher com-pared to those in the fast group, 52% to 77% versus 11% to 13% for complications, and 31% compared to 3% for mortality, respectively.9Frailty AssessmentAs stated earlier, frailty is an important consideration in preop-erative planning for older individuals. Measurement of frailty can | Surgery_Schwartz. timed:1. Stand up from the chair (without using arm rests, if possible)2. Walk to the mark (10 feet in front of them)3. Turn4. Walk back to the chair5. Sit down in the chairA time of ≥15 seconds indicates high risk of falls and should prompt referral to physical therapy for further assessment.In a prospective cohort of individuals age 65 and older undergoing surgery, the TUGT times were stratified into three groups that strongly correlated with varying risk for postop-erative complications and 1-year mortality. These groups were “slow” (≥15 seconds), “intermediate” (11–14 seconds), and “fast” (≤10 seconds). Postoperative complications and 1-year mortality in the slow group were significantly higher com-pared to those in the fast group, 52% to 77% versus 11% to 13% for complications, and 31% compared to 3% for mortality, respectively.9Frailty AssessmentAs stated earlier, frailty is an important consideration in preop-erative planning for older individuals. Measurement of frailty can | [
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Surgery_Schwartz_13376 | Surgery_Schwartz | 31% compared to 3% for mortality, respectively.9Frailty AssessmentAs stated earlier, frailty is an important consideration in preop-erative planning for older individuals. Measurement of frailty can take several forms. One method is to apply the operational definition put forth by Fried (see Table 47-1), which has been applied to surgical patients and shown to be an independent pre-dictor of postoperative adverse events, increased length of stay, and higher likelihood of discharge to a skilled or assisted living facility.5The frailty phenotype, however, may be cumbersome to apply in the busy clinical setting. To this end, Robinson proposed alternative definitions and methods for frailty mea-surement. One such method includes the following criteria: cog-nitive impairment (Mini-Cog score of ≤3), poor nutrition (serum albumin ≤3), history of falls (≥1 fall in the past 6 months), and low hematocrit (<35%).26 A second definition includes func-tional impairment (TUGT ≥15 seconds and | Surgery_Schwartz. 31% compared to 3% for mortality, respectively.9Frailty AssessmentAs stated earlier, frailty is an important consideration in preop-erative planning for older individuals. Measurement of frailty can take several forms. One method is to apply the operational definition put forth by Fried (see Table 47-1), which has been applied to surgical patients and shown to be an independent pre-dictor of postoperative adverse events, increased length of stay, and higher likelihood of discharge to a skilled or assisted living facility.5The frailty phenotype, however, may be cumbersome to apply in the busy clinical setting. To this end, Robinson proposed alternative definitions and methods for frailty mea-surement. One such method includes the following criteria: cog-nitive impairment (Mini-Cog score of ≤3), poor nutrition (serum albumin ≤3), history of falls (≥1 fall in the past 6 months), and low hematocrit (<35%).26 A second definition includes func-tional impairment (TUGT ≥15 seconds and | [
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] |
Surgery_Schwartz_13377 | Surgery_Schwartz | of ≤3), poor nutrition (serum albumin ≤3), history of falls (≥1 fall in the past 6 months), and low hematocrit (<35%).26 A second definition includes func-tional impairment (TUGT ≥15 seconds and dependence in any ADL) and comorbidity (Charlson index score ≥3).28Cognitive and Behavioral AssessmentPreoperative cognitive impairment is strongly linked to postop-erative delirium, worse surgical outcomes, longer hospital stays, increased risk of functional decline, and even mor-tality. History and cognitive assessment are important to con-sider early on in all surgical candidates age 65 years and older in the preoperative setting. The Mini-Cog, consisting of the three-item recall and clock draw tests, can be used to complete this assessment (Table 47-3). If possible, someone who knows the patient well (such as a spouse or family member) should be interviewed about the presence and evolution of any cognitive decline in the patient. If decline is present, the patient should be referred to a | Surgery_Schwartz. of ≤3), poor nutrition (serum albumin ≤3), history of falls (≥1 fall in the past 6 months), and low hematocrit (<35%).26 A second definition includes func-tional impairment (TUGT ≥15 seconds and dependence in any ADL) and comorbidity (Charlson index score ≥3).28Cognitive and Behavioral AssessmentPreoperative cognitive impairment is strongly linked to postop-erative delirium, worse surgical outcomes, longer hospital stays, increased risk of functional decline, and even mor-tality. History and cognitive assessment are important to con-sider early on in all surgical candidates age 65 years and older in the preoperative setting. The Mini-Cog, consisting of the three-item recall and clock draw tests, can be used to complete this assessment (Table 47-3). If possible, someone who knows the patient well (such as a spouse or family member) should be interviewed about the presence and evolution of any cognitive decline in the patient. If decline is present, the patient should be referred to a | [
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Surgery_Schwartz_13378 | Surgery_Schwartz | well (such as a spouse or family member) should be interviewed about the presence and evolution of any cognitive decline in the patient. If decline is present, the patient should be referred to a primary care physician, geriatrician, or mental health specialist for further evaluation. Documentation of pre-operative cognitive status will further assist in the identification of any postoperative cognitive dysfunction.22 Risk factors for postoperative delirium should also be assessed in the preopera-tive period and are detailed in Table 47-4.In addition to measuring cognitive status, assessing the patient’s decision-making capacity is also important to deter-mine the patient’s ability to provide informed surgical consent. It is helpful to ask the patient to describe, in his/her own words, the important features of the discussion, the condition and indi-cations for surgery, and the risks, benefits, and alternatives to surgery. There are four legally-relevant criteria for decision-making | Surgery_Schwartz. well (such as a spouse or family member) should be interviewed about the presence and evolution of any cognitive decline in the patient. If decline is present, the patient should be referred to a primary care physician, geriatrician, or mental health specialist for further evaluation. Documentation of pre-operative cognitive status will further assist in the identification of any postoperative cognitive dysfunction.22 Risk factors for postoperative delirium should also be assessed in the preopera-tive period and are detailed in Table 47-4.In addition to measuring cognitive status, assessing the patient’s decision-making capacity is also important to deter-mine the patient’s ability to provide informed surgical consent. It is helpful to ask the patient to describe, in his/her own words, the important features of the discussion, the condition and indi-cations for surgery, and the risks, benefits, and alternatives to surgery. There are four legally-relevant criteria for decision-making | [
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Surgery_Schwartz_13379 | Surgery_Schwartz | important features of the discussion, the condition and indi-cations for surgery, and the risks, benefits, and alternatives to surgery. There are four legally-relevant criteria for decision-making capacity22:1. The patient can clearly indicate his/her treatment choice.2. The patient understands the relevant information communi-cated by the physician.3. The patient acknowledges his/her medical condition, treat-ment options, and likely outcomes.4. The patient can engage in a rational discussion about the treatment options.Depression should also be screened for in the preoperative setting, as up to 11% of the population age 71 years and older in the United States suffer from this condition.29 Risk factors 2Brunicardi_Ch47_p2045-p2060.indd 204928/02/19 2:08 PM 2050SPECIFIC CONSIDERATIONSPART IITable 47-4Risk factors for postoperative deliriumCognitive and behavioral disorders:• Cognitive impairment and dementia• Untreated or inadequately controlled pain• Depression• Alcohol use• Sleep | Surgery_Schwartz. important features of the discussion, the condition and indi-cations for surgery, and the risks, benefits, and alternatives to surgery. There are four legally-relevant criteria for decision-making capacity22:1. The patient can clearly indicate his/her treatment choice.2. The patient understands the relevant information communi-cated by the physician.3. The patient acknowledges his/her medical condition, treat-ment options, and likely outcomes.4. The patient can engage in a rational discussion about the treatment options.Depression should also be screened for in the preoperative setting, as up to 11% of the population age 71 years and older in the United States suffer from this condition.29 Risk factors 2Brunicardi_Ch47_p2045-p2060.indd 204928/02/19 2:08 PM 2050SPECIFIC CONSIDERATIONSPART IITable 47-4Risk factors for postoperative deliriumCognitive and behavioral disorders:• Cognitive impairment and dementia• Untreated or inadequately controlled pain• Depression• Alcohol use• Sleep | [
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Surgery_Schwartz_13380 | Surgery_Schwartz | 47-4Risk factors for postoperative deliriumCognitive and behavioral disorders:• Cognitive impairment and dementia• Untreated or inadequately controlled pain• Depression• Alcohol use• Sleep deprivationDisease or illness related:• Severe illness or comorbidities• Renal insufficiency• Anemia• HypoxiaMetabolic:• Poor nutrition• Dehydration• Electrolyte abnormalitiesFunctional impairments:• Poor functional status• Immobilization• Hearing or vision impairmentOther:• Older age ≥70 years• Polypharmacy and use of psychotropic medications (benzodiazepines, anticholinergics, and antihistamines)• Risk of urinary retention or constipation, presence of urinary catheterReproduced with permission from Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society, J Am Coll Surg. 2012 Oct;215(4):453-466.Table | Surgery_Schwartz. 47-4Risk factors for postoperative deliriumCognitive and behavioral disorders:• Cognitive impairment and dementia• Untreated or inadequately controlled pain• Depression• Alcohol use• Sleep deprivationDisease or illness related:• Severe illness or comorbidities• Renal insufficiency• Anemia• HypoxiaMetabolic:• Poor nutrition• Dehydration• Electrolyte abnormalitiesFunctional impairments:• Poor functional status• Immobilization• Hearing or vision impairmentOther:• Older age ≥70 years• Polypharmacy and use of psychotropic medications (benzodiazepines, anticholinergics, and antihistamines)• Risk of urinary retention or constipation, presence of urinary catheterReproduced with permission from Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society, J Am Coll Surg. 2012 Oct;215(4):453-466.Table | [
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Surgery_Schwartz_13381 | Surgery_Schwartz | a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society, J Am Coll Surg. 2012 Oct;215(4):453-466.Table 47-3Cognitive assessment: three-item recall and clock draw1. Get the patient’s attention and say: “I am going to say three words that I want you to remember now and later. These words are banana, sunrise, chair. Please say them for me now.” Give the patient three tries to repeat the words. If unable after three tries, go to next item.2. Say all of the following phrases in the order indicated: “Please draw a clock in the space below. Start by drawing a large circle. Put all the numbers in the circle and set the hands to show 11:10 (10 past 11).” If the subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items.3. Say: “What were the three words I asked you to remember?”Scoring:• 3 item recall (0-3 points): 1 point for each correct word• Clock draw (0-2 | Surgery_Schwartz. a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society, J Am Coll Surg. 2012 Oct;215(4):453-466.Table 47-3Cognitive assessment: three-item recall and clock draw1. Get the patient’s attention and say: “I am going to say three words that I want you to remember now and later. These words are banana, sunrise, chair. Please say them for me now.” Give the patient three tries to repeat the words. If unable after three tries, go to next item.2. Say all of the following phrases in the order indicated: “Please draw a clock in the space below. Start by drawing a large circle. Put all the numbers in the circle and set the hands to show 11:10 (10 past 11).” If the subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items.3. Say: “What were the three words I asked you to remember?”Scoring:• 3 item recall (0-3 points): 1 point for each correct word• Clock draw (0-2 | [
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Surgery_Schwartz_13382 | Surgery_Schwartz | in 3 minutes, discontinue and ask for recall items.3. Say: “What were the three words I asked you to remember?”Scoring:• 3 item recall (0-3 points): 1 point for each correct word• Clock draw (0-2 points): 0 points for abnormal clock; 2 points for normal clock A normal clock has all of the following elements: 1. All numbers 1-12, each only once, are present in the correct order and direction (clockwise) inside the circle. 2. Two hands are present, one pointing to 11 and one pointing to 2. 3. Any clock missing any of these elements is scored abnormal. refusal to draw a clock is scored abnormalTotal score of 0, 1, or 2 suggests possible impairmentTotal score of 3, 4, or 5 suggests no impairmentReproduced with permission from Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly, Int J Geriatr Psychiatry. 2000 Nov;15(11):1021-1027.for depression in older adults include female gender, disability, | Surgery_Schwartz. in 3 minutes, discontinue and ask for recall items.3. Say: “What were the three words I asked you to remember?”Scoring:• 3 item recall (0-3 points): 1 point for each correct word• Clock draw (0-2 points): 0 points for abnormal clock; 2 points for normal clock A normal clock has all of the following elements: 1. All numbers 1-12, each only once, are present in the correct order and direction (clockwise) inside the circle. 2. Two hands are present, one pointing to 11 and one pointing to 2. 3. Any clock missing any of these elements is scored abnormal. refusal to draw a clock is scored abnormalTotal score of 0, 1, or 2 suggests possible impairmentTotal score of 3, 4, or 5 suggests no impairmentReproduced with permission from Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly, Int J Geriatr Psychiatry. 2000 Nov;15(11):1021-1027.for depression in older adults include female gender, disability, | [
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Surgery_Schwartz_13383 | Surgery_Schwartz | cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly, Int J Geriatr Psychiatry. 2000 Nov;15(11):1021-1027.for depression in older adults include female gender, disability, bereavement, and sleep disturbance. Poor health status, cogni-tive impairment, living alone, and new medical illness may also contribute to depression.30The Patient Health Questionnaire-2 (PHQ-2) can be used to screen for depression via the following two questions31:1. 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 didn’t care about the tings things that you usually care about or when you didn’t enjoy the things that you usually enjoy?If a patient answers yes to either question, further revalu-ation with a primary care physician, geriatrician, or psychiatrist is recommended.Screening for alcohol and substance abuse | Surgery_Schwartz. cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly, Int J Geriatr Psychiatry. 2000 Nov;15(11):1021-1027.for depression in older adults include female gender, disability, bereavement, and sleep disturbance. Poor health status, cogni-tive impairment, living alone, and new medical illness may also contribute to depression.30The Patient Health Questionnaire-2 (PHQ-2) can be used to screen for depression via the following two questions31:1. 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 didn’t care about the tings things that you usually care about or when you didn’t enjoy the things that you usually enjoy?If a patient answers yes to either question, further revalu-ation with a primary care physician, geriatrician, or psychiatrist is recommended.Screening for alcohol and substance abuse | [
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Surgery_Schwartz_13384 | Surgery_Schwartz | usually enjoy?If a patient answers yes to either question, further revalu-ation with a primary care physician, geriatrician, or psychiatrist is recommended.Screening for alcohol and substance abuse is also recom-mended, as alcohol use is common among older adults. Up to 13% of men and 8% of women ≥65 years consume at least 2 drinks per day and 14.5% of men and 3.3% of women con-sume 5 or more drinks per day.32 Alcohol and substance abuse are associated with increased rates of postoperative mortality and complications including pneumonia, sepsis, wound infec-tion and disruption, and prolonged length of stay.33,34 The ACS NSQIP/AGS recommend screening for alcohol and substance abuse among older individuals with the modified CAGE ques-tionnaire in combination with prescribing daily multivitamins. including folic acid and high dose (100 mg) oral or parenteral thiamine to patients who drink alcohol.22,35Medical AssessmentA thorough medical assessment should be performed in all older | Surgery_Schwartz. usually enjoy?If a patient answers yes to either question, further revalu-ation with a primary care physician, geriatrician, or psychiatrist is recommended.Screening for alcohol and substance abuse is also recom-mended, as alcohol use is common among older adults. Up to 13% of men and 8% of women ≥65 years consume at least 2 drinks per day and 14.5% of men and 3.3% of women con-sume 5 or more drinks per day.32 Alcohol and substance abuse are associated with increased rates of postoperative mortality and complications including pneumonia, sepsis, wound infec-tion and disruption, and prolonged length of stay.33,34 The ACS NSQIP/AGS recommend screening for alcohol and substance abuse among older individuals with the modified CAGE ques-tionnaire in combination with prescribing daily multivitamins. including folic acid and high dose (100 mg) oral or parenteral thiamine to patients who drink alcohol.22,35Medical AssessmentA thorough medical assessment should be performed in all older | [
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Surgery_Schwartz_13385 | Surgery_Schwartz | including folic acid and high dose (100 mg) oral or parenteral thiamine to patients who drink alcohol.22,35Medical AssessmentA thorough medical assessment should be performed in all older operative candidates and should include a cardiac evaluation, pulmonary evaluation, nutritional assessment, and medication evaluation and management where appropriate.Cardiac adverse events are the most common cause of serious perioperative morbidity and mortality among patients undergoing noncardiac operations and occur more commonly in older adults.36,37 For these reasons, cardiac evalu-ation may be helpful to identify older patients with higher risk for cardiac complications who may be candidates for periopera-tive optimization. This evaluation should follow the American College of Cardiology and the American Heart Association (ACC/AHA) algorithm for cardiac evaluation and care. This is a step-wise approach that incorporates the following factors: (a) urgency of surgery (whether the procedure is | Surgery_Schwartz. including folic acid and high dose (100 mg) oral or parenteral thiamine to patients who drink alcohol.22,35Medical AssessmentA thorough medical assessment should be performed in all older operative candidates and should include a cardiac evaluation, pulmonary evaluation, nutritional assessment, and medication evaluation and management where appropriate.Cardiac adverse events are the most common cause of serious perioperative morbidity and mortality among patients undergoing noncardiac operations and occur more commonly in older adults.36,37 For these reasons, cardiac evalu-ation may be helpful to identify older patients with higher risk for cardiac complications who may be candidates for periopera-tive optimization. This evaluation should follow the American College of Cardiology and the American Heart Association (ACC/AHA) algorithm for cardiac evaluation and care. This is a step-wise approach that incorporates the following factors: (a) urgency of surgery (whether the procedure is | [
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Surgery_Schwartz_13386 | Surgery_Schwartz | American Heart Association (ACC/AHA) algorithm for cardiac evaluation and care. This is a step-wise approach that incorporates the following factors: (a) urgency of surgery (whether the procedure is an emergency); the (b) presence of active major cardiac risk factors (i.e., unsta-ble coronary syndromes, decompensated heart failure, signifi-cant arrhythmias or severe valvular disease) that would necessitate referral to a cardiologist; (c) if risk factors for stable coronary artery disease are present, then calculation of risk for major adverse cardiac events using the ACS NSQIP calculator 3Brunicardi_Ch47_p2045-p2060.indd 205028/02/19 2:08 PM 2051SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47is recommended; (d) if the patient is at low risk for major car-diac events (<1%) then no further testing is needed; (e) if the patient is at elevated risk of major cardiac events, then determi-nation of functional capacity with an objective measure or scale may be helpful; (f) if functional | Surgery_Schwartz. American Heart Association (ACC/AHA) algorithm for cardiac evaluation and care. This is a step-wise approach that incorporates the following factors: (a) urgency of surgery (whether the procedure is an emergency); the (b) presence of active major cardiac risk factors (i.e., unsta-ble coronary syndromes, decompensated heart failure, signifi-cant arrhythmias or severe valvular disease) that would necessitate referral to a cardiologist; (c) if risk factors for stable coronary artery disease are present, then calculation of risk for major adverse cardiac events using the ACS NSQIP calculator 3Brunicardi_Ch47_p2045-p2060.indd 205028/02/19 2:08 PM 2051SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47is recommended; (d) if the patient is at low risk for major car-diac events (<1%) then no further testing is needed; (e) if the patient is at elevated risk of major cardiac events, then determi-nation of functional capacity with an objective measure or scale may be helpful; (f) if functional | [
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Surgery_Schwartz_13387 | Surgery_Schwartz | testing is needed; (e) if the patient is at elevated risk of major cardiac events, then determi-nation of functional capacity with an objective measure or scale may be helpful; (f) if functional capacity is poor, then additional testing such as pharmacological stress testing, may be helpful; and finally (g) if testing does not impact care, then one should proceed to surgery or consider alternative treatment strategies.38 Routine electrocardiograms are not indicated in older patients undergoing low-risk surgery in the absence of other risk factors.39-41The combined effect of depletion of intravascular volume, age-related impairment of response to catecholamines, and increased myocardial relaxation time adversely affects the cardiac function of an older adult patient under stress in the perioperative period. Aging has been demonstrated to cause a decrease in cardiac output by approximately 1% per year. Older individuals fail to augment heart rate to the same extent as younger | Surgery_Schwartz. testing is needed; (e) if the patient is at elevated risk of major cardiac events, then determi-nation of functional capacity with an objective measure or scale may be helpful; (f) if functional capacity is poor, then additional testing such as pharmacological stress testing, may be helpful; and finally (g) if testing does not impact care, then one should proceed to surgery or consider alternative treatment strategies.38 Routine electrocardiograms are not indicated in older patients undergoing low-risk surgery in the absence of other risk factors.39-41The combined effect of depletion of intravascular volume, age-related impairment of response to catecholamines, and increased myocardial relaxation time adversely affects the cardiac function of an older adult patient under stress in the perioperative period. Aging has been demonstrated to cause a decrease in cardiac output by approximately 1% per year. Older individuals fail to augment heart rate to the same extent as younger | [
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Surgery_Schwartz_13388 | Surgery_Schwartz | in the perioperative period. Aging has been demonstrated to cause a decrease in cardiac output by approximately 1% per year. Older individuals fail to augment heart rate to the same extent as younger individuals. More importantly, the ability to increase cardiac output with aging is dependent on ventricular dilatation, which is determined by preload. Therefore, careful attention must be paid to volume status in the perioperative period. Over one half of all postoperative deaths in older adult patients and 11% of postoperative complications are a result of impaired car-diac function under physiologic stress. Incomplete emptying of the ventricle at end systole and subsequent reduction in ejection fraction is characteristic of the aging heart. Reduced distensibil-ity, in addition to acute stressors, leads to impaired coronary perfusion and cardiac ischemia.An important predictor of surgical outcomes and cardiac complications in the older adult is congestive heart failure (CHF). CHF is | Surgery_Schwartz. in the perioperative period. Aging has been demonstrated to cause a decrease in cardiac output by approximately 1% per year. Older individuals fail to augment heart rate to the same extent as younger individuals. More importantly, the ability to increase cardiac output with aging is dependent on ventricular dilatation, which is determined by preload. Therefore, careful attention must be paid to volume status in the perioperative period. Over one half of all postoperative deaths in older adult patients and 11% of postoperative complications are a result of impaired car-diac function under physiologic stress. Incomplete emptying of the ventricle at end systole and subsequent reduction in ejection fraction is characteristic of the aging heart. Reduced distensibil-ity, in addition to acute stressors, leads to impaired coronary perfusion and cardiac ischemia.An important predictor of surgical outcomes and cardiac complications in the older adult is congestive heart failure (CHF). CHF is | [
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Surgery_Schwartz_13389 | Surgery_Schwartz | stressors, leads to impaired coronary perfusion and cardiac ischemia.An important predictor of surgical outcomes and cardiac complications in the older adult is congestive heart failure (CHF). CHF is present in approximately 10% of patients older than 65 years and is the leading cause of postoperative morbid-ity and mortality. This prevalence will likely increase as per-cutaneous interventions and medical therapy prolongs survival from myocardial ischemia and acute myocardial infarction. Therefore, identifying correctable and uncorrectable cardiovas-cular disease is critical before elective surgical interventions.Common pulmonary postoperative complications in older adults include atelectasis, pneumonia, and prolonged mechanical ventilation.42 These complications can contribute significantly to overall morbidity and mortality among older adults, affecting up to 15% of individuals ≥70 years in the postoperative setting.22,43 Risk factors for postoperative pulmonary complications | Surgery_Schwartz. stressors, leads to impaired coronary perfusion and cardiac ischemia.An important predictor of surgical outcomes and cardiac complications in the older adult is congestive heart failure (CHF). CHF is present in approximately 10% of patients older than 65 years and is the leading cause of postoperative morbid-ity and mortality. This prevalence will likely increase as per-cutaneous interventions and medical therapy prolongs survival from myocardial ischemia and acute myocardial infarction. Therefore, identifying correctable and uncorrectable cardiovas-cular disease is critical before elective surgical interventions.Common pulmonary postoperative complications in older adults include atelectasis, pneumonia, and prolonged mechanical ventilation.42 These complications can contribute significantly to overall morbidity and mortality among older adults, affecting up to 15% of individuals ≥70 years in the postoperative setting.22,43 Risk factors for postoperative pulmonary complications | [
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Surgery_Schwartz_13390 | Surgery_Schwartz | to overall morbidity and mortality among older adults, affecting up to 15% of individuals ≥70 years in the postoperative setting.22,43 Risk factors for postoperative pulmonary complications include both patient and procedure-related factors. Patient-related fac-tors include age >60, chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists (ASA) class II or greater, functional dependence, congestive heart failure, obstructive sleep apnea, pulmonary hypertension, current ciga-rette use, impaired sensorium, preoperative sepsis, weight loss >10% in 6 months, serum albumin <3.5 mg/dL, and blood urea nitrogen (BUN) ≥7.5 mmol/L (≥1.5 mg/dL). Surgical related fac-tors include prolonged operation of greater than 3 hours, surgi-cal site, emergency operation, general anesthesia, perioperative transfusion, and residual neuromuscular blockade after an opera-tion. Of note, obesity, well-controlled asthma, and diabetes are not risk factors for postoperative pulmonary | Surgery_Schwartz. to overall morbidity and mortality among older adults, affecting up to 15% of individuals ≥70 years in the postoperative setting.22,43 Risk factors for postoperative pulmonary complications include both patient and procedure-related factors. Patient-related fac-tors include age >60, chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists (ASA) class II or greater, functional dependence, congestive heart failure, obstructive sleep apnea, pulmonary hypertension, current ciga-rette use, impaired sensorium, preoperative sepsis, weight loss >10% in 6 months, serum albumin <3.5 mg/dL, and blood urea nitrogen (BUN) ≥7.5 mmol/L (≥1.5 mg/dL). Surgical related fac-tors include prolonged operation of greater than 3 hours, surgi-cal site, emergency operation, general anesthesia, perioperative transfusion, and residual neuromuscular blockade after an opera-tion. Of note, obesity, well-controlled asthma, and diabetes are not risk factors for postoperative pulmonary | [
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Surgery_Schwartz_13391 | Surgery_Schwartz | anesthesia, perioperative transfusion, and residual neuromuscular blockade after an opera-tion. Of note, obesity, well-controlled asthma, and diabetes are not risk factors for postoperative pulmonary complications. It is recommended that patients with COPD and asthma that is not well controlled undergo preoperative optimization of pulmonary function and other general recommendations include smoking cessation, preoperative intensive inspiratory muscle training, and selective chest radiograph and pulmonary function testing.22In general, the use of routine preoperative screening com-bined with the high cost of unnecessary testing dispute the use of a routine battery of preoperative screening tests in all patients. Instead, it is preferable to perform selected tests in high-risk patients based on history, physical exam, known comorbidities, and the type of procedure being planned.22Nutritional AssessmentNutritional status should also be performed in older adults prior to surgery, as poor | Surgery_Schwartz. anesthesia, perioperative transfusion, and residual neuromuscular blockade after an opera-tion. Of note, obesity, well-controlled asthma, and diabetes are not risk factors for postoperative pulmonary complications. It is recommended that patients with COPD and asthma that is not well controlled undergo preoperative optimization of pulmonary function and other general recommendations include smoking cessation, preoperative intensive inspiratory muscle training, and selective chest radiograph and pulmonary function testing.22In general, the use of routine preoperative screening com-bined with the high cost of unnecessary testing dispute the use of a routine battery of preoperative screening tests in all patients. Instead, it is preferable to perform selected tests in high-risk patients based on history, physical exam, known comorbidities, and the type of procedure being planned.22Nutritional AssessmentNutritional status should also be performed in older adults prior to surgery, as poor | [
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Surgery_Schwartz_13392 | Surgery_Schwartz | on history, physical exam, known comorbidities, and the type of procedure being planned.22Nutritional AssessmentNutritional status should also be performed in older adults prior to surgery, as poor nutrition is potentially modifiable and related to increased risk of postoperative complications. The most com-mon adverse events related to poor nutritional status are infec-tious complications (i.e., surgical site infections, pneumonia, urinary tract infections), wound complications (i.e., dehiscence and anastomotic leaks), and increased length of stay. The ACS NSQIP/AGS best practice guidelines recommend the following to screen for poor nutritional status:1. Document height and weight and calculate body mass index (BMI). A BMI <18.5 kg/m2 places an individual at risk and should prompt referral for full nutritional assessment.2. Measure baseline serum albumin and prealbumin levels. Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction) should prompt referral for full | Surgery_Schwartz. on history, physical exam, known comorbidities, and the type of procedure being planned.22Nutritional AssessmentNutritional status should also be performed in older adults prior to surgery, as poor nutrition is potentially modifiable and related to increased risk of postoperative complications. The most com-mon adverse events related to poor nutritional status are infec-tious complications (i.e., surgical site infections, pneumonia, urinary tract infections), wound complications (i.e., dehiscence and anastomotic leaks), and increased length of stay. The ACS NSQIP/AGS best practice guidelines recommend the following to screen for poor nutritional status:1. Document height and weight and calculate body mass index (BMI). A BMI <18.5 kg/m2 places an individual at risk and should prompt referral for full nutritional assessment.2. Measure baseline serum albumin and prealbumin levels. Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction) should prompt referral for full | [
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Surgery_Schwartz_13393 | Surgery_Schwartz | for full nutritional assessment.2. Measure baseline serum albumin and prealbumin levels. Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction) should prompt referral for full nutritional assessment.3. Inquire about unintentional weight loss in the last year. Unintentional weight loss >10% to 15% in the past 6 months is associated with severe nutritional risk and should prompt assessment by a dietician.22The American Society for Parenteral and Enteral Nutrition (ASPEN) argues that measurement of serum albumin and pre-albumin reflect the severity of the inflammatory response rather than true poor nutritional status. Instead, they favor a more indi-vidualized approach whereby the presence of any of the follow-ing six factors would classify an individual with malnutrition:1. Insufficient energy intake. Severe malnutrition in the context of chronic illness is defined as <75% of estimated energy requirement for ≥1 month.2. Weight loss. Severe malnutrition in the context | Surgery_Schwartz. for full nutritional assessment.2. Measure baseline serum albumin and prealbumin levels. Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction) should prompt referral for full nutritional assessment.3. Inquire about unintentional weight loss in the last year. Unintentional weight loss >10% to 15% in the past 6 months is associated with severe nutritional risk and should prompt assessment by a dietician.22The American Society for Parenteral and Enteral Nutrition (ASPEN) argues that measurement of serum albumin and pre-albumin reflect the severity of the inflammatory response rather than true poor nutritional status. Instead, they favor a more indi-vidualized approach whereby the presence of any of the follow-ing six factors would classify an individual with malnutrition:1. Insufficient energy intake. Severe malnutrition in the context of chronic illness is defined as <75% of estimated energy requirement for ≥1 month.2. Weight loss. Severe malnutrition in the context | [
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Surgery_Schwartz_13394 | Surgery_Schwartz | energy intake. Severe malnutrition in the context of chronic illness is defined as <75% of estimated energy requirement for ≥1 month.2. Weight loss. Severe malnutrition in the context of chronic illness is defined as >5% weight loss in 1 month, >7.5% weight loss in 3 months, >10% weight loss in 6 months, and >20% weight loss in 1 year.3. Loss of muscle mass. Severe malnutrition is defined as severe muscle wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, thigh, and calf.4. Loss of subcutaneous fat. Severe malnutrition is defined as loss of subcutaneous fat (e.g., orbital, triceps, fat overlying the ribs).5. Localized or generalized fluid accumulation that may sometimes mask weight loss. This can be demonstrated by fluid accumulation evident on exam (e.g., extremities, vulvar/scrotal edema, or ascites).6. Diminished functional status as measured by hand grip strength. Measurements for grip strength are based on nor-mative standards supplied by the | Surgery_Schwartz. energy intake. Severe malnutrition in the context of chronic illness is defined as <75% of estimated energy requirement for ≥1 month.2. Weight loss. Severe malnutrition in the context of chronic illness is defined as >5% weight loss in 1 month, >7.5% weight loss in 3 months, >10% weight loss in 6 months, and >20% weight loss in 1 year.3. Loss of muscle mass. Severe malnutrition is defined as severe muscle wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, thigh, and calf.4. Loss of subcutaneous fat. Severe malnutrition is defined as loss of subcutaneous fat (e.g., orbital, triceps, fat overlying the ribs).5. Localized or generalized fluid accumulation that may sometimes mask weight loss. This can be demonstrated by fluid accumulation evident on exam (e.g., extremities, vulvar/scrotal edema, or ascites).6. Diminished functional status as measured by hand grip strength. Measurements for grip strength are based on nor-mative standards supplied by the | [
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Surgery_Schwartz_13395 | Surgery_Schwartz | extremities, vulvar/scrotal edema, or ascites).6. Diminished functional status as measured by hand grip strength. Measurements for grip strength are based on nor-mative standards supplied by the manufacturer of the mea-surement device.44Regardless of the method used to measure nutritional sta-tus, attention to the diagnosis and management of malnutrition in the perioperative setting is imperative to optimize postopera-tive outcomes.4Brunicardi_Ch47_p2045-p2060.indd 205128/02/19 2:08 PM 2052SPECIFIC CONSIDERATIONSPART IIPsychosocial ConsiderationsAnxiety, depression, substance abuse, and social isolation are common, underdiagnosed conditions in older adults. Careful screening can identify these potential barriers to recovery, safe discharge after surgery, and maintenance of independence.Medication ReviewCareful review and documentation of the patient’s complete med-ication history is important in the preoperative setting. The review should include the use of nonprescription agents, | Surgery_Schwartz. extremities, vulvar/scrotal edema, or ascites).6. Diminished functional status as measured by hand grip strength. Measurements for grip strength are based on nor-mative standards supplied by the manufacturer of the mea-surement device.44Regardless of the method used to measure nutritional sta-tus, attention to the diagnosis and management of malnutrition in the perioperative setting is imperative to optimize postopera-tive outcomes.4Brunicardi_Ch47_p2045-p2060.indd 205128/02/19 2:08 PM 2052SPECIFIC CONSIDERATIONSPART IIPsychosocial ConsiderationsAnxiety, depression, substance abuse, and social isolation are common, underdiagnosed conditions in older adults. Careful screening can identify these potential barriers to recovery, safe discharge after surgery, and maintenance of independence.Medication ReviewCareful review and documentation of the patient’s complete med-ication history is important in the preoperative setting. The review should include the use of nonprescription agents, | [
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Surgery_Schwartz_13396 | Surgery_Schwartz | ReviewCareful review and documentation of the patient’s complete med-ication history is important in the preoperative setting. The review should include the use of nonprescription agents, including over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs), vitamins, eye drops, topical agents, and herbal products.Additionally, it is important to discontinue medications that should be avoided prior to surgery in order to minimize potential adverse events and interactions. These include dis-continuation of all nonessential medications that are associated with increased surgical risk and medications with potential for drug interactions with anesthesia. Herbal medication should be stopped at least 7 days prior to surgery, and the Beers criteria should be reviewed. Medications with potential for withdrawal (e.g., selective serotonin reuptake inhibitor [SSRIs], tricyclic antidepressants, benzodiazepines, antipsychotics, monoamine oxidase inhibitors [MAOIs], β-blockers, clonidine, | Surgery_Schwartz. ReviewCareful review and documentation of the patient’s complete med-ication history is important in the preoperative setting. The review should include the use of nonprescription agents, including over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs), vitamins, eye drops, topical agents, and herbal products.Additionally, it is important to discontinue medications that should be avoided prior to surgery in order to minimize potential adverse events and interactions. These include dis-continuation of all nonessential medications that are associated with increased surgical risk and medications with potential for drug interactions with anesthesia. Herbal medication should be stopped at least 7 days prior to surgery, and the Beers criteria should be reviewed. Medications with potential for withdrawal (e.g., selective serotonin reuptake inhibitor [SSRIs], tricyclic antidepressants, benzodiazepines, antipsychotics, monoamine oxidase inhibitors [MAOIs], β-blockers, clonidine, | [
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Surgery_Schwartz_13397 | Surgery_Schwartz | for withdrawal (e.g., selective serotonin reuptake inhibitor [SSRIs], tricyclic antidepressants, benzodiazepines, antipsychotics, monoamine oxidase inhibitors [MAOIs], β-blockers, clonidine, statins, and corticosteroids) in addition to angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers should be con-tinued unless hypertension is well controlled. Medications that are associated with increased risk for postoperative delirium should also be avoided and replaced with safer medications. For example, benzodiazepines should be stopped or reduced, where possible. Pain should be adequately controlled and meperi-dine should be avoided for pain management. Caution should be used when prescribing antihistamine H1 antagonists (such as diphenhydramine/Benadryl) and medications with antihista-mine effects. Of note, there is no increased risk associated with neuroleptics (antipsychotics) and digoxin and no conclusive evi-dence against using H2 agonists, tricyclic | Surgery_Schwartz. for withdrawal (e.g., selective serotonin reuptake inhibitor [SSRIs], tricyclic antidepressants, benzodiazepines, antipsychotics, monoamine oxidase inhibitors [MAOIs], β-blockers, clonidine, statins, and corticosteroids) in addition to angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers should be con-tinued unless hypertension is well controlled. Medications that are associated with increased risk for postoperative delirium should also be avoided and replaced with safer medications. For example, benzodiazepines should be stopped or reduced, where possible. Pain should be adequately controlled and meperi-dine should be avoided for pain management. Caution should be used when prescribing antihistamine H1 antagonists (such as diphenhydramine/Benadryl) and medications with antihista-mine effects. Of note, there is no increased risk associated with neuroleptics (antipsychotics) and digoxin and no conclusive evi-dence against using H2 agonists, tricyclic | [
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Surgery_Schwartz_13398 | Surgery_Schwartz | medications with antihista-mine effects. Of note, there is no increased risk associated with neuroleptics (antipsychotics) and digoxin and no conclusive evi-dence against using H2 agonists, tricyclic antidepressants, anti-Parkinson medications, steroids, NSAIDs, and antimuscarinics in the perioperative setting.Certain medications, such as β-blockers or statins, may be beneficial to start preoperatively in order to reduce risk of perioperative adverse events such as cardiac complications and stroke. There are ACC/AHA guidelines to support the use of perioperative β-blockers in patients who are already taking them, particularly those with independent cardiac indications such as arrhythmia or history of myocardial infarction and in patients who are undergoing intermediate risk or vascular surgery with no known coronary artery disease or with multiple clinical risk factors for ischemic heart disease. Statins should be started as soon as possible prior to surgery in patients who have known | Surgery_Schwartz. medications with antihista-mine effects. Of note, there is no increased risk associated with neuroleptics (antipsychotics) and digoxin and no conclusive evi-dence against using H2 agonists, tricyclic antidepressants, anti-Parkinson medications, steroids, NSAIDs, and antimuscarinics in the perioperative setting.Certain medications, such as β-blockers or statins, may be beneficial to start preoperatively in order to reduce risk of perioperative adverse events such as cardiac complications and stroke. There are ACC/AHA guidelines to support the use of perioperative β-blockers in patients who are already taking them, particularly those with independent cardiac indications such as arrhythmia or history of myocardial infarction and in patients who are undergoing intermediate risk or vascular surgery with no known coronary artery disease or with multiple clinical risk factors for ischemic heart disease. Statins should be started as soon as possible prior to surgery in patients who have known | [
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Surgery_Schwartz_13399 | Surgery_Schwartz | with no known coronary artery disease or with multiple clinical risk factors for ischemic heart disease. Statins should be started as soon as possible prior to surgery in patients who have known vascular disease, elevated low-density lipoprotein cholesterol, or ischemia on thallium testing. They may also be considered in patients undergoing vascular and intermediate-risk surgery.Additionally, medications doses should be adjusted based on renal function. Older patients are at greater risk for renal impairment and chronic kidney disease; furthermore, adjustment of medications that are renally cleared is an important consider-ation. Glomerular filtration rate (GFR), rather than creatinine, is the best overall measure of renal function due to the fact that the ratio of GFR to creatinine decreases with increasing age.22Finally, medication use is very common among the older population, and older individuals should be monitored for polypharmacy and potential adverse interactions. This is of | Surgery_Schwartz. with no known coronary artery disease or with multiple clinical risk factors for ischemic heart disease. Statins should be started as soon as possible prior to surgery in patients who have known vascular disease, elevated low-density lipoprotein cholesterol, or ischemia on thallium testing. They may also be considered in patients undergoing vascular and intermediate-risk surgery.Additionally, medications doses should be adjusted based on renal function. Older patients are at greater risk for renal impairment and chronic kidney disease; furthermore, adjustment of medications that are renally cleared is an important consider-ation. Glomerular filtration rate (GFR), rather than creatinine, is the best overall measure of renal function due to the fact that the ratio of GFR to creatinine decreases with increasing age.22Finally, medication use is very common among the older population, and older individuals should be monitored for polypharmacy and potential adverse interactions. This is of | [
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Surgery_Schwartz_13400 | Surgery_Schwartz | with increasing age.22Finally, medication use is very common among the older population, and older individuals should be monitored for polypharmacy and potential adverse interactions. This is of real concern since 40% of individuals age 65 years and older are taking five or more medications prescribed by more than one doctor.45 Additionally, 68% of older adults use over-the-counter medications, dietary supplements, or both concurrently with prescription medications.46 Of note, polypharmacy has been associated with increased risk of cognitive impairment, morbidity, and mortality, and the risk of adverse drug reactions increases with a greater number of medications.45,47Patient CounselingDetermination of the patient’s preferences and expectations prior to surgery is an essential component to preoperative assessment and decision making. One study demonstrated that agreement between patients and their surrogates (primary care providers and close family members) was poor, despite patients | Surgery_Schwartz. with increasing age.22Finally, medication use is very common among the older population, and older individuals should be monitored for polypharmacy and potential adverse interactions. This is of real concern since 40% of individuals age 65 years and older are taking five or more medications prescribed by more than one doctor.45 Additionally, 68% of older adults use over-the-counter medications, dietary supplements, or both concurrently with prescription medications.46 Of note, polypharmacy has been associated with increased risk of cognitive impairment, morbidity, and mortality, and the risk of adverse drug reactions increases with a greater number of medications.45,47Patient CounselingDetermination of the patient’s preferences and expectations prior to surgery is an essential component to preoperative assessment and decision making. One study demonstrated that agreement between patients and their surrogates (primary care providers and close family members) was poor, despite patients | [
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Surgery_Schwartz_13401 | Surgery_Schwartz | preoperative assessment and decision making. One study demonstrated that agreement between patients and their surrogates (primary care providers and close family members) was poor, despite patients predicting that their physicians (90%) and family members (87%) would accurately represent their wishes. Instead, they found that per-cent of agreement ranged from 59% to 88%, suggesting that sub-stituted judgement may not be a good proxy for an individual patient’s wishes.48 Another study looked at older patients with limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease and found that 99% of patients would undergo a low-burden treatment to restore current health (with the alternative being death), but that 74% and 89% would forgo treatment if it resulted in severe functional or cognitive impairment, respectively.49 Furthermore, it is imperative that the surgeon have a substantive discussion with the patient prior to sur-gery to determine | Surgery_Schwartz. preoperative assessment and decision making. One study demonstrated that agreement between patients and their surrogates (primary care providers and close family members) was poor, despite patients predicting that their physicians (90%) and family members (87%) would accurately represent their wishes. Instead, they found that per-cent of agreement ranged from 59% to 88%, suggesting that sub-stituted judgement may not be a good proxy for an individual patient’s wishes.48 Another study looked at older patients with limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease and found that 99% of patients would undergo a low-burden treatment to restore current health (with the alternative being death), but that 74% and 89% would forgo treatment if it resulted in severe functional or cognitive impairment, respectively.49 Furthermore, it is imperative that the surgeon have a substantive discussion with the patient prior to sur-gery to determine | [
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