Skip to main content
SpringerLink
Log in

Perioperative care of the elderly patient

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Surgical risk increases with age, primarily from loss of cardiac and pulmonary reserve. Complications are tolerated poorly by the elderly, emphasizing the importance of their prediction and prevention. Surgical risk in this population is significant, but with careful preoperative assessment and perioperative management acceptable morbidity and mortality are possible. This review proposes a general approach to the elderly surgical patient and applies it to the most significant sources of morbidity and mortality: pulmonary and cardiac complications. Risk assessment based on validated tools is utilized, and perioperative management recommendations based on the state of the art are examined. In addition, pulmonary embolism and postoperative confusion are examined separately with the same overall strategy.

Résumé

Le risque opératoire augmente avec l'âge, principalement par diminution des capacités cardiaque et respiratoire. Chez les sujets âgés les complications sont mal tolérées, soulignant l'importance de l'appréciation de leur risque et de leur prévention. Le risque opératoire dans cette population est non négligeable mais grâce à une évaluation pré-opératoire et une prise en charge péri-opératoire soigneuses, il est possible de réduire la morbidité et la mortalité à des taux acceptables. Cette étude propose une prise en charge globale du sujet âgé chirurgical et l'applique aux causes les plus courantes de morbidité et de mortalité c'est à dire les complications pulmonaires et cardiaques. L'évaluation du risque est faite au moyen de scores validés et il est tenu compte dans la prise en charge périopératoire de ces patients de l'état actuel des conaissances. De plus, l'embolie pulmonaire et les syndromes confusionnels post-opératoires sont étudiés séparément avec la même stratégie globale.

Resumen

El riesgo quirúrgico se aumenta con la edad fundamentalmente por pérdida de reserva cardiaca y pulmonar. Las complicaciones son mal toleradas por el anciano, lo cual destaca la importancia de su predicción y prevención. El riesgo quirúrgico en la población de edad avanzada es significativo, pero mediante una cuidadosa valoración preoperatoria y el debido manejo perioperatorio, se logran aceptables tasas de morbilidad y mortalidad. La presente revisión propone un aproche general al paciente quirúrgico de edad avanzada y su aplicación a las fuentes más significativas de morbilidad y mortalidad: las complicacione pulmonares y cardiacas. La valoración del riesgo basada en métodos de validez reconocida son utilizados y se analizan las recomendaciones de manejo perioperatorio con fundamento en el estado del arte. Además, se analizan el embolismo pulmonar y el estado de confusión mental postoperatorio, por separado pero utilizando la misma estrategia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Meakins, J.L., McClaran, J.C., editors: Surgical Care of the Elderly. Chicago, Year Book, 1988

    Google Scholar 

  2. U.S. Senate Special Committee on Aging in conjunction with the American Associations of Retired Persons, the Federal Council on Aging, and the U.S. Administration on Aging: Aging America: Trends and Projections 1987–88. Washington, DC, US Senate, pp. 8–38

  3. Vowles, K.J.D.: Surgical Problems in the Aged. Bristol, John Wright & Sons, 1979

    Google Scholar 

  4. Politser, P., Schneidman, D.: American College of Surgeons: Socio-economic Factbook for Surgery 1990. Chicago, American College of Surgeons, 1990

    Google Scholar 

  5. Linn, B.S., Linn, M.W., Wallen, N.: Evaluation of results of surgical procedures in the elderly. Ann. Surg.195:90, 1982

    Google Scholar 

  6. Adkins, R.B., Scott, H.W.: Surgical procedures in patients aged 90 years and older. South. Med. J.77:1357, 1984

    Google Scholar 

  7. Andersen, B., Otsberg, J.: Long-term prognosis in geriatric surgery: 2–17 years follow-up of 7922 patients. J. Am. Geriatr. Soc.20:255, 1972

    Google Scholar 

  8. Puxty, J.A.H., Horan, M.A.: Necropsies in the elderly. Lancet1:1262, 1983

    Google Scholar 

  9. Palmberg, S., Hirsjarvi, E.: Mortality in geriatric surgery. Gerontology25:103, 1979

    Google Scholar 

  10. Millar, H.R.: Psychiatric morbidity in elderly surgical patients. Br. J. Psychiatry138:17, 1982

    Google Scholar 

  11. Seymour, D.G., Pringle, R.: Post-operative complications in the elderly surgical patient. Gerontology29:262, 1983

    Google Scholar 

  12. Tisi, G.: Preoperative evaluation of pulmonary function. Am. Rev. Respir. Dis.119:293, 1979

    Google Scholar 

  13. Stein, M., Koota, G.M., Simon, M., Frank, H.A.: Pulmonary evaluation of surgical patients. J.A.M.A.181:765, 1962

    Google Scholar 

  14. Boghosian, S.G.H.: Usefulness of routine preoperative chest roentgenograms in elderly patients. J. Am. Geriatr. Soc.35:142, 1987

    Google Scholar 

  15. Belman, M.J., Mittman, C.: Preoperative evaluation of the surgical patient. In Textbook of Pulmonary Diseases, G.L. Baum, E. Wolinsky, editors. Boston, Little, Brown, 1989, pp. 337–352

    Google Scholar 

  16. Seymour, D.G.: Medical Assessment of the Elderly Surgical Patient. Rockville, MD, Aspen, 1986

    Google Scholar 

  17. Dripps, R.D., Deming, M.V.H.: Postoperative atelectasis and pneumonia. Ann. Surg.124:94, 1946

    Google Scholar 

  18. Stein, M., Cassara, E.L.: Preoperative pulmonary evaluation and therapy for surgery patients. J.A.M.A.211:787, 1970

    Google Scholar 

  19. Warner, M.A., Tinker, J.H., Divertie, M.B.: Preoperative cessation of smoking and pulmonary complications in pulmonary dysfunction. Anesthesiology59:A60, 1983

    Google Scholar 

  20. Celli, B.R., Rodrigues, K.S., Snider, G.L.: A controlled trial of intermittent positive-pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after surgery. Am. Rev. Respir. Dis.130:12, 1984

    Google Scholar 

  21. Tisi, G.M.: Pulmonary Physiology in Clinical Medicine, 2nd ed. Baltimore, Williams & Wilkins, 1983, pp. 113–131

    Google Scholar 

  22. Cuschieri, R.J., Morran, C.G., Howie, D.C., McArdle, C.S.: Postoperative pain and pulmonary complications: comparison of three analgesic regimens. Br. J. Surg.72:495, 1985

    Google Scholar 

  23. Breyer, R.H., Zippe, C., Pharr, W.F., Jensik, R.J., Kittle, C.F., Faber, L.P.: Thoracotomy in patients over seventy years. J. Thorac. Cardiovasc. Surg.81:187, 1981

    Google Scholar 

  24. Sherman, S., Guidot, C.E.: The feasibility of thoracotomy for lung cancer in the elderly. J.A.M.A.258:927, 1987

    Google Scholar 

  25. Kannell, W.B., McGee, D., Gordon, T.: A general cardiovascular risk profile: the Framingham Study. Am. J. Cardiol.38:46, 1976

    Google Scholar 

  26. Tarhan, S., Moffit, E.A., Taylor, W.F., Giulani, E.R.: Myocardial infarction after general anesthesia. J.A.M.A.220:1451, 1964

    Google Scholar 

  27. Steen, P.A., Tinker, J.H., Tarhan, S.: Myocardial reinfarction after anesthesia and surgery. J.A.M.A.239:2566, 1978

    Google Scholar 

  28. Goldman, L., Caldera, D.L., Nussbaum, S.R., Southwick, F.S., Krogstad, D., Murray, B., Burke, D.S., O'Malley, T.A., Goroll, A.H., Caplan, C.H., Nolan, J., Carabello, B., Slater, E.E.: Multifactorial index of cardiac risk in noncardiac surgical procedures. N. Engl. J. Med.297:845, 1977

    Google Scholar 

  29. Slater, E.E.: Multifactorial index of cardiac risk in noncardiac surgical procedures. N. Engl. J. Med.297:845, 1977

    Google Scholar 

  30. Rao, T.L.K., Jacobs, K.H., El-Etr, A.A.: Reinfarction following anesthesia in patients with myocardial infarction. Anesthesiology59:499, 1983

    Google Scholar 

  31. Wells, P.H., Kaplan, J.A.: Optimal management of patients with ischemic heart disease for noncardiac surgery by complementary anesthesiologist and cardiologist interaction. Am. Heart J.102:1029, 1981

    Google Scholar 

  32. Goldman, L.: Cardiac risks and complications of noncardiac surgery. Ann. Intern. Med.98:504, 1983

    Google Scholar 

  33. Detsky, A.S., Abrams, H.B., McLaughlin, J.R., Drucker, D.J., Sasson, Z., Johnston, N., Scott, J.G., Forbath, N., Hilliard, J.R.: Predicting cardiac complications in patients undergoing noncardiac surgery. J. Gen. Intern. Med.1:211, 1986

    Google Scholar 

  34. Gerson, M.C., Hurst, J.M., Hertzberg, V.S., Doogan, P.A., Cochran, M.B., Lim, S.P., McCall, N., Adolph, R.J.: Cardiac prognosis in noncardiac geriatric surgery. Ann. Intern. Med.103:832, 1985

    Google Scholar 

  35. Tomatis, L.A., Fierens, E.E., Verbrugge, G.P.: Evaluation of surgical risk in peripheral vascular disease by coronary arteriography: series of 100 cases. Surgery71:429, 1972

    Google Scholar 

  36. Jeffrey, C.C., Kunsman, J., Cullen, D.J., Brewster, D.C.: A prospective evaluation of cardiac risk index. Anesthesiology58:462, 1983

    Google Scholar 

  37. Raby, K.E., Goldman, L., Creager, M.A., Cook, E.F., Weisberg, M.C., Whittemore, A.D., Selwin, A.P.: Correlation between pre-operative ischemia and major cardiac events after peripheral vascular surgery. N. Engl. J. Med.321:1296, 1989

    Google Scholar 

  38. Cutler, B.S., Wheeler, H.B., Paraskos, J.A., Cardullo, P.A.: Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease. Am. J. Surg.141:501, 1981

    Google Scholar 

  39. Eagle, K.A., Boucher, C.A.: Cardiac risk of noncardiac surgery. N. Engl. J. Med.321:1330, 1989

    Google Scholar 

  40. Ockene, I.S., Nimer, M.A.: Noncardiac surgery in the cardiac patient. In Intensive Care Medicine, J.M. Rippe, R.S. Irwin, J.S. Alpert, M.P. Fink, editors. Boston, Little, Brown, 1991, pp. 1368–1376

    Google Scholar 

  41. Brown, D.L., Kirby, R.R.: Preoperative evaluation of high-risk elective surgical patients. In Critical Care, J.M. Civetta, R.W. Taylor, R.R. Kirby, editors. Philadelphia, Lippincott, 1988, pp. 137–44

    Google Scholar 

  42. Savino, J.A., Del Guercio, L.R.M.: Hemodynamic monitoring in the elderly. In Surgical Care of the Elderly, J.L. Meakins, J.C. McClaran, editors. Chicago, Year Book, 1988, pp. 249–265

    Google Scholar 

  43. Del Guercio, L.R.M., Cohn, J.D.: Monitoring operative risk in the elderly. J.A.M.A.243:1350, 1980

    Google Scholar 

  44. Babu, S.C., Sharma, P.V.P., Raciti, A., Mayr, C.H., Elrabie, N.A., Clauss, R.H., Stahl, W.M., Del Guercio, L.R.M.: Monitor-guided responses: operability with safety is increased in patients with peripheral vascular diseases. Arch. Surg.115:1384, 1980

    Google Scholar 

  45. Gewertz, B.L., Kremser, P.C., Zarins, C.K., Smith, J.S., Ellis, J.E., Feinstein, S.B., Roizen, M.F.: Transesophageal echocardiographic monitoring of myocardial ischemia during vascular surgery. J. Vasc. Surg.5:607, 1987

    Google Scholar 

  46. Bell, W.R., Simon, T.L.: Current status of pulmonary thromboembolic disease: pathophysiology, diagnosis, prevention, and treatment. Am. Heart J.103:239, 1982

    Google Scholar 

  47. Coon, W.W.: The spectrum of pulmonary embolism: twenty years later. Arch. Surg.111:398, 1976

    Google Scholar 

  48. Collins, R.C., Scrimgeour, A., Yusuf, S., Peto, R.: Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. N. Engl. J. Med.318:1162, 1988

    Google Scholar 

  49. Seymour, D.G., Vaz, F.G.: A prospective study of elderly general surgical patients. II. Postoperative complications. Age Aging18:316, 1989

    Google Scholar 

  50. Lipowski, Z.J.: Delirium in the elderly patient. N. Engl. J. Med.320:578, 1989

    Google Scholar 

  51. Diagnostic and Statistical Manual of Mental Disorders: DSM-IIIR, 3rd ed. Washington, DC, American Psychiatric Press, 1987

  52. Krechel, S.W.: Anesthesia for surgical care of the elderly. In Surgical Care of the Elderly, J.L. Meakins, J.C. McClaran, editors. Chicago, Year Book, 1988, pp. 276–286

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, Division of Geriatrics, Montreal, Quebec, Canada

    Patrick Lee Ergina M.D., M.P.H., F.R.C.S.(C.), Susan L. Gold M.D. & Jonathan L. Meakins M.D., D.Sc., F.R.C.S.(C.), F.A.C.S.

  2. Department of Surgery, McGill University, Montreal, Quebec, Canada

    Patrick Lee Ergina M.D., M.P.H., F.R.C.S.(C.), Susan L. Gold M.D. & Jonathan L. Meakins M.D., D.Sc., F.R.C.S.(C.), F.A.C.S.

  3. Sir Mortimer B. Davis-Jewish General Hospital and Royal Victoria Hospital, Montreal, Quebec, Canada

    Patrick Lee Ergina M.D., M.P.H., F.R.C.S.(C.), Susan L. Gold M.D. & Jonathan L. Meakins M.D., D.Sc., F.R.C.S.(C.), F.A.C.S.

Authors
  1. Patrick Lee Ergina M.D., M.P.H., F.R.C.S.(C.)
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Susan L. Gold M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jonathan L. Meakins M.D., D.Sc., F.R.C.S.(C.), F.A.C.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ergina, P.L., Gold, S.L. & Meakins, J.L. Perioperative care of the elderly patient. World J. Surg. 17, 192–198 (1993). https://doi.org/10.1007/BF01658926

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01658926

Keywords

Search

Navigation