Management of the Surgical Patient

Peter Pompei

CLINICAL PEARLS

Operative therapy can be an effective management option for many health problems affecting older persons.
Surgery can be done with few complications in older patients.
Risk indices that help stratify patients and practice guidelines to optimize management have been developed for cardiac, pulmonary, and neuropsychiatric problems.
Consider discontinuing angiotensin-converting enzyme (ACE) inhibitors before surgery.
Most medications can be taken with small sips of water on the morning of surgery.
β-Blockers have been shown to decrease the risk of cardiovascular events during surgery.
Effective prophylactic measures exist for patients who are at risk for bacterial endocarditis, thromboembolism, and delirium.
Respiratory complications can be reduced by using incentive spirometry and early mobility after surgery.
Generally give two thirds of the usual dose of insulin for a morning procedure and one half for an afternoon procedure. Hold oral hypoglycemics.
Restore a euthyroid state before elective procedures.
Pain or a distended bladder may raise blood pressure postoperatively.
Ten percent to 30% of older patients suffer postoperative cognitive decline that lasts for months or may be permanent.
Effective chronic disease management through comprehensive preoperative assessment and attentive perioperative care can minimize complications of surgical interventions.

Use of health care services by older persons is high and disproportionate to the number of persons aged 65 years and older in the population. This holds true for the special case of operative interventions as well. Currently, it is estimated that of all adults operated on each year, one third are in the 65 years and above age-group. Among persons who reach the age of 65, at least half will undergo surgery in the remaining years of their lives. Advances in technology that address the diseases afflicting older persons are partly responsible for these utilization patterns. Common surgeries that older persons undergo include cataract extraction and intraocular lens implantation, revascularization procedures, joint replacements, cholecystectomy, and bowel resections.

Another reason for the increased number of surgical procedures among older persons is the recent significant decline in operative risk. Over the last 50 years, operative mortality among patients aged 80 years and older has decreased from approximately 10% to below 3%. This change has been ascribed to advances in anesthesiology and newer surgical techniques, including safer anesthetic agents and limited-access approaches such as laparoscopic procedures. Because the complication rates for urgent and emergent procedures remain high for older persons—three to ten times greater than for younger persons—planned procedures with sufficient time to optimize the management of a patient’s health status are always preferred. Operative risk has consistently been found to be related to the burden of comorbidity rather than to the age of the patient. Consistent findings are that, even among patients aged 75 years and older, those with few comorbid conditions have a low risk of complications, and this risk is directly related to the number and severity of coexisting illnesses. Although the functional reserve of any organ may decline with advancing age, it is the presence of disease processes, chronic and acute, that significantly compromise homeostatic mechanisms.

The generalist physicians caring for the older person during the perioperative period have several responsibilities. First, they are frequently called on by surgical colleagues to identify and modify risk factors that may predispose the patient to specific complications. Second, to reduce the risk of complications, they must optimally manage all the acute and chronic medical problems of the patient throughout the perioperative period. Third, whenever possible, generalist physicians should initiate and maintain appropriate preventive strategies to reduce the risk of selected complications. Finally, they should understand, as fully as possible, the wishes and advance directives of the patient in case of a serious complication. A discussion about personal values and wishes, preferences for future interventions, and the surrogate decision makers to be involved when necessary can be critical in ensuring a comprehensive patient-centered treatment plan.

PREOPERATIVE ASSESSMENT AND MANAGEMENT

Evaluating a patient’s risk for select complications and intervening to modify these risks are important functions of the preoperative assessment. The most common complications involve the respiratory, cardiac, and neuropsychiatric systems, so these require special attention. Ensuring the optimal management of concurrent medical problems and instituting preventive measures to reduce the risk of morbidity and mortality from a surgical procedure are other important functions of a preoperative assessment. Most of the evidence-based approaches for assessing and managing patients before surgery are organ or system based.

Cardiovascular System

Hypertension is one of the most commonly encountered chronic diseases affecting the cardiovascular system. Perioperative complications from hypertension including stroke and myocardial infarction are associated with both excessive elevations and wide fluctuations of blood pressure. Patients with well-controlled hypertension should be maintained on their antihypertensive regimen as much as possible throughout the perioperative period. For elective procedures, the morning doses of the patients’ medications should be taken with a sip of water before the induction of anesthesia. The one exception to this recommendation relates to angiotensin-converting enzyme (ACE) inhibitors, which may interact with anesthetic agents to cause severe hypotension; some recommend that this class of medication be withheld on the morning of surgery.¹ According to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, when the preoperative diastolic blood pressure exceeds 110 mm Hg, surgery should be delayed.² The blood pressure should be reduced gradually with medications over several weeks, although this decision must be made in conjunction with a full understanding of the potential benefits and urgency of the proposed operative intervention. Hypertension is often a marker for vascular diseases that are associated with adverse surgical outcomes. It is reasonable to assess older patients with hypertension with a detailed history and physical examination to uncover coronary disease, congestive heart failure, and cerebrovascular disease and obtain an electrocardiogram, looking for changes of ischemia or left ventricular hypertrophy. Because hypertension can lead to chronic kidney disease, it is useful to measure the serum creatinine level and estimate the glomerular filtration rate.

Cardiac complications of noncardiac surgery are among the most serious, and a number of risk indices have been developed over the years. As the ability to reliably predict the patients who are at risk for cardiac complications improved, practice guidelines were developed to identify and manage this risk. The stepwise algorithm advocated by the American College of Cardiology (ACC) and the American Heart Association (AHA) is updated regularly to incorporate the latest evidence from clinical trials.³ According to this guideline, the clinician should consider three major factors in sequence: Clinical predictors of risk, the functional capacity of the patient, and the risks specific to the planned surgery. As shown in Table 7.1, clinical predictors are grouped as minor, intermediate, or major. It is notable that advanced age is categorized as a minor clinical predictor, acknowledging that the increased operative risk to older persons is attributable to accumulated medical problems and not age alone. Patients with intermediate or minor clinical predictors of risk are next assessed for functional capacity, as defined in Table 7.2. Those with minor or no clinical predictors who also have moderate or excellent functional capacity can proceed to the operating room. For patients who
have either minor clinical predictors and poor functional capacity or intermediate clinical predictors and moderate or excellent functional capacity, the degree of risk associated with the planned surgery is considered. If the surgical risk is low or intermediate, as listed in Table 7.3, the patients can proceed to the operating room. Delaying the noncardiac surgery for additional testing and management is recommended for the following three groups of patients: (i) Those who are undergoing a high-risk surgery who have poor functional capacity, (ii) those undergoing a high-risk procedure who have intermediate clinical predictors, (iii) those who have major clinical predictors, irrespective of their functional capacity or the surgical risk. As with all practice guidelines, the algorithm is intended to assist physicians in meeting the needs of most patients in most circumstances; individual treatment plans are best made jointly by the treating physician and the patient.

TABLE 7.1 CLINICAL PREDICTORS OF INCREASED PERIOPERATIVE CARDIAC RISK FOR NONCARDIAC SURGERY

Minor Predictors	Intermediate Predictors	Major Predictors
Advanced age	Mild angina pectoris	Unstable coronary syndromes
Abnormal ECG	Prior myocardial infarction	Significant dysrhythmias
Rhythm other than sinus	Compensated or prior heart failure	Decompensated heart failure
Low functional capacity	Diabetes mellitus	Severe valvular disease
History of stroke	Renal insufficiency
Uncontrolled hypertension
ECG, electrocardiogram.
From Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to update the 1996 Guidelines on perioperative cardiovascular evaluation for noncardiac surgery). American College of Cardiology; 2002. Available at: http://www.acc.org/clinical/guidelines/perio/dirIndex.htm used with permission.

TABLE 7.2 EXAMPLES OF ACTIVITIES THAT HELP STRATIFY PATIENTS ACCORDING TO FUNCTIONAL CAPACITY

Poor Functional Capacity (Maximal Energy Expenditure ≤4 METs)		Moderate/Excellent Functional Capacity (Maximal Energy Expenditure >4 METs)
▪	Eating, dressing, using the toilet	▪	Climbing a flight of stairs or walking up a hill
▪	Walking indoors around the house	▪	Running a short distance
▪	Walking a block or two on ground level	▪	Scrubbing floors or moving furniture
▪	Doing light housework—dusting, washing dishes	▪	Playing golf, bowling, dancing
	Doing light housework—dusting, washing dishes	▪	Swimming, singles tennis, skiing
METs, metabolic equivalents.
From Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to update the 1996 Guidelines on perioperative cardiovascular evaluation for noncardiac surgery). American College of Cardiology; 2002. Available at: http://www.acc.org/clinical/guidelines/perio/dirIndex.htm used with permission.

Accumulating evidence supports the use of β-blocker therapy perioperatively to reduce the risks of cardiac complications in noncardiac surgery.⁴ Despite variations in drug administration (i.e., oral vs. parenteral; initiating the drug either weeks before or immediately before the surgery; discontinuing the drug immediately, at 48 hours, at hospital discharge, at 7 days, or at 30 days; or titrating the dose to different heart rates), β-blockers have been found to significantly decrease postoperative cardiac ischemia, myocardial infarction, and death. The number of patients who would need to be treated in order to achieve benefit is fewer than ten. The success of empiric β-blocker therapy in reducing cardiac risk may obviate the need for preoperative noninvasive testing in some patients.

Valvular heart disease can predispose surgical patients to congestive heart failure, myocardial ischemia, and endocarditis. Severe aortic stenosis, one of the major clinical
predictors in the ACC/AHA practice guideline reviewed in the preceding text, can be asymptomatic and difficult to distinguish from the more benign aortic sclerosis common in older persons. If the systolic murmur is heard with the stethoscope placed over the right clavicle, the chances of moderate or severe aortic stenosis are increased. Patients with this finding should be examined for the following clinical findings: (i) Reduced carotid artery volume, (ii) delayed carotid artery upstroke, (iii) reduced intensity of the second heart sound, and (iv) maximum intensity of the murmur over the second right intercostal space. If three of these four findings are present, the risk of significant aortic stenosis is sufficient to warrant confirmation by an echocardiogram.⁵

TABLE 7.3 RISKS OF CARDIAC COMPLICATIONS ASSOCIATED WITH SPECIFIC NONCARDIAC SURGERIES

High Risk (>5%)		Intermediate Risk (<5%)		Low Risk (<1%)
▪	Emergent major surgeries	▪	Carotid endarterectomy	▪	Endoscopic procedures
▪	Aortic and other major vascular surgery	▪	Head and neck surgery	▪	Superficial procedures
▪	Aortic and other major vascular surgery	▪	Intraperitoneal and intrathoracic surgery	▪	Cataract surgery
▪	Peripheral vascular surgery	▪	Intraperitoneal and intrathoracic surgery	▪	Breast surgery
▪	Prolonged procedures with large fluid shifts and/or blood loss	▪	Orthopaedic surgery
▪		▪	Prostate surgery
From Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to update the 1996 Guidelines on perioperative cardiovascular evaluation for noncardiac surgery). American College of Cardiology; 2002. Available at: http://www.acc.org/clinical/guidelines/perio/dirIndex.htm used with permission.