Perioperative Management Of Elderly Patients Research Articles

Navigating anemia and anticoagulation in elderly patients undergoing orthopedic surgery: strategies for preventing complications and implementing treatments.

Elderly populations face an increased risk of anemia, leading to elevated transfusion requirements during surgery, especially major orthopedic procedures. Anemia itself increases the risk of thromboembolic events, thus compounding complications in elderly individuals. Polypharmacy and the prevalent use of oral anticoagulants (OAC), particularly for atrial fibrillation, contribute to bleeding risks in this population. Data available in the literature on the peri-operative management of anemia in patients taking OAC is limited and often heterogeneous. This narrative case-based review focuses on the peri-operative management of elderly patients on OAC undergoing major orthopedic surgery. PubMed/Medline was used to search for relevant literature. With reference to two cases, we critically evaluate the literature, and focus on risk factors, and preventive and therapeutic strategies as fundamental tools to reduce bleeding and correct anemia as soon as possible in elderly patients undergoing major orthopedic surgery. Peri-operative management of these patients, especially those on OAC, requires a balanced approach considering bleeding and thrombotic risks. Intravenous iron therapy and tranexamic acid emerge as valuable strategies in minimizing transfusion requirements and optimizing patients' outcomes.

Frailty is associated with an increased risk of postoperative pneumonia in elderly patients following surgical treatment for lower-extremity fractures: A cross-sectional study.

Elderly patients with lower-extremity fractures are at high risk of postoperative pneumonia (POP) after surgery due to longtime bed rest. This study aimed to explore whether preoperative frailty is an independent risk factor for POP in elderly patients undergoing surgical treatment for lower-extremity fractures. The study adopted a cross sectional design with 568 patients (≥60 years) admitted to a tertiary hospital in China from January 1, 2021 to June 30, 2022, for surgical intervention of a significant lower-extremity fracture. Preoperative frailty was assessed using the CFS (Clinical Frailty Scale). POP was assessed based on the classic diagnostic criteria reported in previous studies. Univariate and multiple logistic regression analyses were conducted to determine the impacts of preoperative frailty on POP. Of the 568 elderly patients, 65 (11.4%) developed pneumonia during postoperative hospitalization. There were significant differences among gender, hypoproteinemia, type of anesthesia, history of chronic obstructive pulmonary disease (COPD), and CFS scores. Multiple regression analysis revealed that the risk of POP in vulnerable, mildly frail, and severely frail patients increased by 2.38 times (P = .01, 95% CI [1.22-1.91]), 3.32 (P = .00, 95% CI [2.39-5.61]), and 5.36 (P = .00, 95% CI [3.95-6.52]), significantly. 12.8% of patients with hip fractures and 8.9% of patients with other main types of lower-extremity fractures developed POP. However, the difference between hip and non-hip fractures was not statistically significant (P > .05). Preoperative frailty increases the risk of POP in elderly patients after surgical treatment of main lower-extremity fractures. The severer the preoperative frailty is, the higher the risk of preoperative pneumonia is in elderly patients with lower-extremity fractures. CFS is simple and feasible for the assessment of frailty in elderly patients with lower-extremity fractures. Preoperative frailty assessment and appropriate management strategies should be considered in the perioperative management of elderly patients with lower-extremity fractures.

The enhanced recovery after surgery (ERAS) protocol in elderly patients with acute cholecystitis: A retrospective study.

Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.

SUCCESSFUL PERIOPERATIVE MANAGEMENT OF HIGH-RISK ELDERLY PATIENTS WITH ADVANCED HEAD &amp; NECK CANCER IN THE COVID ERA. OUR EXPERIENCE.

INTRODUCTION: Elderly patients with advanced head and neck cancer undergoing major surgery are at high risk due to their co-morbidities and prolonged procedures. Thus, they often require admission in the ICU. PURPOSE: We herein describe the perioperative management of elderly patients, with significant comorbidities, surgically treated for stage II-IV head and neck cancer with a specialized anesthesia protocol in the COVID-19 era. MATERIAL - METHOD: In total, 11 consecutive patients (4 female, 7 male, mean age 74 years, ASA III-IV), with advanced cancer involving oral mucosa, salivary glands and metastatic skin cancer were treated in UHL between 3/2021 and 3/2022. Operation duration varied from 5 to 13 hours, as the extent of disease necessitated extirpation and reconstruction with free or regional flaps in most cases. Hence, an individualized and patient-centered approach was implemented, with the preanesthetic evaluation, the utilization of both an enhanced recovery (ERAS), specialized anesthesia protocol and the prompt postoperative care delivered by the anesthesia team. . RESULT: No intraoperative adverse events were reported. Admissions in ICU were obviated. One patient underwent neck exploration for bleeding control being treated with therapeutic doses of LMWH (grade IIIb Clavien-Dindo). One more patient required blood transfusion (grade II Clavien-Dindo). Donor site wound breakdown was recorded in 4 patients (grade IIIa Clavien-Dindo). Hospital length ranged from 5 to 14 days. 30-day mortality was 0%. CONCLUSION: Good rapport between involved teams along with the implementation of an individualized perioperative approach of this patient cohort resulted in an uneventful outcome amid the COVID-19 pandemic.

Perioperative management of elderly and senile patients. Recommendations

Perioperative management of elderly patients remains one of the most difficult tasks of modern anesthesiology. Compared with younger patients, people over 60 years of age have a higher risk of developing adverse postoperative outcomes, as a result of age-related decline in physiological functions, the presence of several concomitant diseases, polypragmasia, cognitive dysfunction and specific geriatric syndromes, such as frailty. More than 25 % of this category of people have several chronic diseases of the cardiovascular, nervous, endocrine, hematopoietic, musculoskeletal systems, respiratory, digestive and other systems. In the process of aging, there is also a decrease and some perversion of metabolic processes, a decrease in the reactivity of the body. All of the above, along with the surgical intervention, increases the risk of postoperative complications and perioperative mortality. The recommendations present the definition of the category of elderly and senile patients, provide information about age-related changes in their body that affect anesthesia and intensive care. The main clinical syndromes and symptoms useful in predicting the unfavorable course of the perioperative period are indicated, including frailty, nutritional insufficiency, sarcopenia and cognitive dysfunction. Methods for assessing functional activity and the risk of falls are given separately. Attention is paid to the causes, diagnosis, prevention and treatment of delirium, cardiovascular, respiratory complications. The principles of choosing the method of anesthesia and management of the perioperative period in elderly and senile patients, depending on the features of interventions and concomitant pathology, are described.

Perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty.

Knee osteoarthritis is a common arthritic disease which mainly affects the elderly (≥65 years old) population. As a result of the cartilage degeneration, it can cause a significant amount of pain and functional limitation. In patients who are refractory to conservative management, total knee arthroplasty is being utilised as the last resort in management. In this review, we discuss the perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty.

Relationship between comorbidities and treatment decision-making in elderly hip fracture patients

BackgroundElderly patients are at a higher risk for hip fracture. Moreover, hospitalized elderly patients with hip fracture are vulnerable to adverse outcomes including higher mortality rate and long-term disability. Treatment decision-making with respect to surgical procedure and perioperative management of these patients is typically challenging owing to the presence of multiple comorbid conditions.AimsThe purpose of this study was to investigate the relationship between comorbidities in elderly patients with hip fracture and the treatment decision-making.Methods884 geriatric patients (age ≥ 60 years) with hip fracture were included. Comorbidities related to age were measured using the Charlson Co-morbidity Index (CCI) and age-adjusted CCI. The CCI of each geriatric hip fracture patient was calculated based on data retrieved from the medical records. The relationship of CCI and age-adjusted CCI with surgical procedure, time-to-surgery, length of hospital stay, and perioperative management (transfusion, anti-coagulation, and analgesia) was assessed.ResultsMean age of patients was 78.01 ± 8.62 years. The mean CCI was 0.79 ± 0.036; the mean age-adjusted CCI was 4.15 ± 0.047. The CCI was significantly associated with time-to-surgery (P = 0.004), surgical treatment (P < 0.001), and transfusion (P = 0.023). The age-adjusted CCI was significantly associated with surgical treatment (P < 0.001), analgesia (P = 0.003) and transfusion (P < 0.001). The length of hospital stay was associated with both CCI (P = 0.041), age-adjusted CCI (P = 0.002), and hypertension (P = 0.012). Hospital expenses showed a significant association with CCI (P = 0.000), age-adjusted CCI (P = 0.029), osteoprosis (P = 0.007), and hypertension (P = 0.001).ConclusionIn this study, comorbidities were positively associated with surgical procedure and perioperative management of elderly patients with hip fracture.

Management of Patients Taking Oral Anticoagulants Who Need Urgent Surgery for Hip Fracture.

The number of hip fractures in anticoagulated patients is predicted to increase, due to people living longer. However, evidence regarding urgent perioperative management of elderly patients with hip fracture who take oral anticoagulants (vitamin K antagonists or direct oral anticoagulants) is scarce. In this article, the authors present a narrative review of the evidence to date supporting the urgent management of hip fracture in anticoagulated elderly patients. They discuss the complexity of managing the high risk of procedure-related bleeding and, at the same time, the high risk of thromboembolism. The role of a bridging procedure and the best strategy of anticoagulation reversal are also reviewed. Further studies are required to improve the evidence in urgent surgery, especially in frail elderly patients.

Interactive online learning on perioperative management of elderly patients

IntroductionSurgical specialists and residents lack knowledge to adequately manage frail older patients. This study aims to evaluate the effects of an interactive online course regarding attitude, self-confidence and knowledge in perioperative management of the elderly patient. MethodsThe six-weeks course consisted of expert videos, literature readings, quizzes and forum discussions. Surgical consultants with geriatric expertise and geriatricians moderated online discussions and stimulated interaction. Knowledge, self-confidence and attitude of course participants were compared at the beginning and end of the course. Results206 medical practitioners started the course. Knowledge scores improved significantly from 49% to 65% (p < 0.005). Participants felt more secure (p < 0.005) in the treatment of the older patient at the end of the course. A better attitude correlated with a higher total knowledge score in surgeons and surgical residents (p = 0.02). ConclusionA six-week interactive online course on perioperative management of elderly patients increases relevant geriatric knowledge and improves self-confidence of residents and faculty.

Hepatobiliary Oncologic Surgery in the Elderly

This review aims to describe the treatment and outcomes in the perioperative management of elderly patients undergoing hepatic surgery for cancer. There is a broad perception that elderly patients are more frail and less able to tolerate major resection. They are therefore offered surgery less often than younger patients. Elderly patients can tolerate major hepatectomies with comparable length of surgery, rate of transfusion, and length of hospital stay as younger patients. However, they are more apt to develop significant cardiopulmonary complications and require discharge to an acute care facility. When matched for tumor stage, disease-specific survival is similar to younger patients. Contrary to what is sometimes perceived, elderly patients can tolerate major hepatic resection. However, this requires careful patient selection and preoperative evaluation, as elderly patients are more prone to complications, concerns related to quality of life outcomes and perioperative mortality.

Peculiarities of the Perioperative Care of Elderly Patients Undergoing Endoscopic Transsphenoidal Removal of Tumors in the Chiasmatic-Sellar Area

Nowadays, in the age of rapid introduction of digital and fiber-optic technologies in neurosurgery, a technique for removal of tumors in the chiasmatic-sellar area via an endoscopic transsphenoidal endonasal approach is actively developed; this technique is considered less invasive and is well tolerated by patients, thus permitting to operate patients with somatic complications, as well as the elderly. Taking into account these facts, as well as world statistic data indicating a continuous trend of population aging in developed countries, including Russia, optimization of the perioperative care of elderly patients with a tumor of the chiasmatic-sellar area becomes the problem of highest priority. In order to solve it, this review discusses the basic peculiarities of the perioperative management of elderly patients (characteristics of their somatic status and possible variants of the pre-operational state) with a pathology in the chiasmatic-sellar region; it also presents the modern and most acceptable alternative solutions of this difficult problem (introduction of modern methods of anesthesia, management of the postoperative cognitive dysfunction, postoperative pain syndrome, and postoperative nausea and vomiting).

Perioperative management of elderly patients undergoing surgery with regional anesthesia

Regional anesthesia can reduce deep vein thrombosis and pulmonary embolism by suppression of the stress responses caused by surgery via the blocking of the afferent and efferent pathways of nerve conduction. It is also effective for control of acute postoperative pain, and compared to general anesthesia, it reduces bleeding during surgery and postoperative respiratory complications. The functional reserves of important organs are reduced in elderly patients although the progression and degree are different from patient to patient. Thus, it is important that safe and appropriate perioperative care including anesthesia be delivered only after a thorough evaluation of the current status of an elderly patient. In this regard, regional anesthesia is worth performing for elderly patients considering its characteristic advantages over general anesthesia. Peripheral nerve blocks using ultrasound are another alternative in elderly patients who might have difficulty undergoing regional or general anesthesia.

Perioperative management of elderly patients suffering a hip fracture

Preparing elderly patients for emergency hip fracture surgery is a significant challenge for hospital staff. This article discusses the principles of preoperative care in these patients, and the rationale for such strategies, based on evidence and current guidelines. Such guidance increasingly reflects a national standard of care.

A new care paradigm in geriatric head and neck surgical oncology

Perioperative management of elderly patients with head and neck cancer poses unique challenges. Our objective is to describe the implementation and feasibility of a novel intervention designed to improve perioperative care in geriatric head and neck surgery. This pilot study was performed in a single-institution, NCI-designated comprehensive cancer center. All surgical patients with head and neck cancer over age 75 were offered perioperative consultation with fellowship-trained geriatricians focusing in geriatric oncology. Between 2010 and 2011, a total of 168 patients requiring head and neck surgery were seen by the geriatric service, of which 94% subsequently underwent surgery. Apart from preoperative medical optimization, geriatricians assisted in complex decision-making regarding the indications for cancer-directed therapy. Postoperatively, they assisted in preventing and treating delirium and poly-pharmacy, facilitating discharge planning, and initiating rehabilitation. Postoperatively, 87% were discharged home, and 13% required placement in skilled nursing facilities. At 24 months, overall survival was 80%. Patients, surgeons and geriatricians alike were enthusiastic about the initiative, which is expanding within the institution. Geriatric perioperative support for elderly head and neck cancer patients is well-received with promising potential. The tangible impact and direct benefits of this pilot initiative require additional study.

A New Paradigm in Geriatric Head and Neck Surgical Oncology

Objective: Perioperative management of elderly patients with head and neck cancer poses unique challenges and may benefit from expert input from geriatricians. Our objectives are to 1) describe the implementation and 2) determine the feasibility of a novel intervention designed to improve perioperative care delivery in geriatric head and neck surgery. Method: In this pilot study, patients with head and neck cancer over age 75 were offered preoperative consultation with fellowship-trained geriatricians. Geriatric-specific assessment included functional and social status, cognitive testing, medication review and nutrition; patients were also optimized and risk-stratified for surgery. Thereafter, patients were seen postoperatively by the geriatric service. Results: Between 2010 and 2011, a total of 176 head and neck patients (75-93 years old) were seen by the geriatric service. Apart from preoperative medical optimization, geriatricians also assisted in complex decision-making regarding the indications for cancer-directed therapy. From the cohort, 148 (84%) subsequently underwent surgery; the majority of cases involved mucosal lesions (43%), cutaneous lesions (20%), and endocrine disease (16%). Postoperatively, geriatricians assisted in preventing and treating delirium, minimizing inappropriate prescribing and poly-pharmacy, facilitating discharge planning, and initiating prompt rehabilitation. Surgeons, geriatricians, and nursing staff alike were enthusiastic about the initiative, which continues to expand within the institution. Conclusion: Geriatric perioperative assessment of elderly head and neck cancer patients is feasible and well-received with promising potential. The tangible impact and direct benefits of this pilot initiative require additional study.

Perioperative management of elderly patients with degenerative lumbar scoliosis

Perioperative management of elderly patients with degenerative lumbar scoliosis

Priorities in perioperative geriatrics.

T he aging of the baby-boom population and the decreases in adult mortality seen in the last few decades will dramatically increase the age of Americans between 2010 and 2030. During that time, the population older than age 65 yr is expected to grow by 75%, whereas between 1995 and 2050, the cumulative growth of the population older than 85 yr is expected to exceed 400% (1). Furthermore, it has been reported that the increased demand for surgery in this population may exceed the rate of population growth (2). The implications of an aging population for the practice of anesthesiology are profound. Age-related changes in physiology and pharmacology can affect every aspect of perioperative care. The changes in surgical demographics will compel the anesthesiologist to become familiar with the physiology and clinical care of the aged. This review will serve as an introduction. First, some of the physiologic changes that occur with aging will be presented. Second, the preoperative assessment of the older surgical patient will be discussed. Third, some of the research related to intraoperative management of the geriatric surgical patient will be described. In the fourth section, we will discuss some geriatric-specific issues related to postoperative management.