Perioperative Issues

Some 50 years ago, surgery was considered to be too risky for elderly patients. Today, centenarians undergo a wide variety of surgical procedures. The development of information regarding the perioperative care of elderly surgical patients is in its infancy; however, there is some information that suggests pathways caring for these patients. Ther wordperioperative refers to the complete experience surrounding an operative procedure—deciding to have an operation, preparing for surgery, undergoing anesthesia, recovering from the surgery, and getting back to the expected level of function (which may include active rehabilitation).

The principal risk to patients undergoing surgery is not chronological age but rather a combination of physiological age and disease load. A robust 90-year-old may have a relatively low risk from undergoing many surgical procedures, whereas a 65-year-old with disease in one or more systems may be at high risk.

When making a decision to undergo surgery, patients should understand that techniques have evolved rapidly. An impressive example is the treatment of abdominal aortic aneurysms. In the past, this disease, in which the largest artery of the body becomes enlarged and distorted and can burst, thereby causing rapid death, was treated with a very involved open abdomen surgical operation that required days in an intensive care unit (ICU). Currently, the same disease frequently can be treated by passing a replacement tube into the ballooned vessel by passing a very sophisticated device by way of an artery in the groin. The development of such endovascular (operating from inside the blood vessels) techniques require very short recovery times with very little pain, and the patient frequently goes home the following morning. Many procedures in the abdomen are accomplished using laparoscopes; that is, instruments that allow surgeons to operate through three or four small (quarter-inch) holes rather than a long incision in the middle of the belly. These “minimally invasive” techniques appear to have significant benefit for elderly surgical candidates when they can be used safely.

Because getting old and developing illness tend to occur simultaneously, coordinated perioperative care includes paying attention to general medical conditions with the perspective of both assessing function and, where possible, improving or maximizing the function of a particular body system. A general preoperative history and physical examination should indicate whether any additional testing is required. For example, if the patient has congestive heart failure, a circumstance in which the pumping function of the heart is limited, special tests are frequently requested to assess that function. Occasionally, doctors find other medical problems that should be fixed before surgery.

Some sort of anesthesia is required for all surgical procedures. Some procedures, such as removal of lesions of the skin and removal of cataracts (i.e., when the lens of the eye becomes white and the patient cannot see through it), can be performed by using medications called local anesthetics to numb the affected area. The risk of these procedures is very limited. For some procedures, local anesthesia is supplemented [Page 458]with additional drugs to diminish pain and provide sedation. Major procedures require either general anesthesia or a major regional technique. General anesthesia involves the administration of drugs either by direct injection into the blood or by inhalation. From the patient's perspective, the principal feature of general anesthesia is loss of consciousness. Regional anesthesia blocks nerve transmission at different levels. For operations on the lower body, techniques that block the nerves of the spinal cord can be used. Spinal or subarachnoid anesthesia administers local anesthetic agents directly around the lower spinal cord and nerves. It is accomplished by placing a small needle in the back. Spinal anesthesia produces complete numbness and lack of motor control (i.e., the patient cannot move his or her legs) but does not change the patient's level of consciousness. The anesthesia can last from 1 to 6 hours depending on the drugs used. Additional sedation can be administered if necessary. An epidural is a similar technique in which the local anesthetic is administered to the nerves at the space where they leave the spine. This technique is generally done with a small catheter that is left in the epidural space. This allows continuous administration of local anesthetic drugs so that the anesthesia can last as long as needed. Epidural catheters can also be used to provide pain relief after surgery. Although there are very strong advocates for regional anesthetic techniques, multiple studies have failed to demonstrate a significant difference in morbidity or mortality between regional and general anesthesia. Particularly for orthopedic procedures such as hip and knee replacements, the choice between regional and general anesthesia is based on local practice. The risks of anesthesia have decrease markedly over the past few decades. During general anesthesia, the anesthesiologist is responsible for maintaining respirations for the patient because the drugs typically impair breathing. In this regard, local anesthesia with sedation is frequently described as limited and safe because it is not general anesthesia. However, elderly patients are extremely sensitive to anesthetic drugs, so the line between sedation and general anesthesia is difficult to determine. Undertaking a procedure under deep sedation without airway control is not safer than doing so with a planned general anesthetic. There is also a group of regional anesthesia techniques that block nerves in an arm or a leg and can be very effective in providing anesthesia in the operating room and pain relief after surgery.

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