Joint Guideline Addresses Geriatric Perioperative Care

Laurie Barclay, MD

January 11, 2016

The American College of Surgeons (ACS) and American Geriatrics Society (AGS) have issued joint best practice recommendations for geriatric perioperative care. The consensus-based guideline was published online January 4 on the ACS National Surgical Quality Improvement Program website.

"As a start, this guideline functions as an unprecedented educational resource, one that organizes all of the components of perioperative care of the older adult in one place," guideline coauthor Sanjay Mohanty, MD, an ACS/AGS James C. Thompson Geriatrics Surgical Fellow from Henry Ford Hospital, said in a news release. "Moving forward, perhaps it will one day play an important role in informing us about process, and providing us with insightful metrics on outcomes for geriatric surgical patients."

Expert guidance on surgical care for the geriatric population is essential, because older adults living in the United States now exceed 40 million and are expected to increase to 89 million by 2050. Furthermore, postoperative complications and recovery time tend to increase with increasing age.

To develop the guideline, an expert multidisciplinary panel reviewed current literature evidence and best practices to formulate expert recommendations aimed at surgeons, anesthesiologists, and other members of the geriatric healthcare team.

"[T]he AGS recognizes that expanding geriatrics expertise means ensuring that all healthcare professionals — not just geriatrics experts — know and can employ principles of excellence in eldercare," AGS Chief Executive Officer Nancy E. Lundebjerg, MPA, said in the news release. "This collaboration builds on the legacy of our Geriatrics-for-Specialists Initiative, which itself underscores the unique importance of geriatrics awareness for surgeons and related medical specialists."

The recommendations address immediate preoperative, intraoperative, and postoperative management, as well as managing transition to care after surgery. The guideline also includes various checklists and appendices, such as advance directive position statements and perioperative risk factors for delirium.

Immediate preoperative management encompasses patient goals, preferences, and advance directives; preoperative fasting; antibiotic prophylaxis; venous thromboembolism prevention; and medication management.

The intraoperative management section discusses anesthesia, perioperative analgesia, perioperative nausea and vomiting, patient safety, strategies to prevent postoperative complications and hypothermia, fluid management, and fine-tuning physiological parameters.

The postoperative management section addresses postoperative delirium, functional decline, and preventing pulmonary complications, falls, urinary tract infections, and pressure ulcers.

Some specific recommendations include the following:

  • The healthcare team should discuss the patient's personal goals and treatment preferences before surgery, including advance directive and a designated healthcare proxy.

  • Provide an early postoperative palliative care consultation for patients with a poor prognosis.

  • Stratify patients for venous thromboembolism and bleeding risk, using a structured approach.

  • Evidence is insufficient to recommend a single "best" anesthetic plan for all older adults or to determine whether regional anesthesia is preferable to general anesthesia.

  • Before surgery, develop an appropriate, multimodal analgesic plan, including opioid-sparing techniques and avoiding potentially inappropriate analgesics and anxiolytics.

  • Proper positioning and padding of bony prominences should help maintain skin integrity and limit pressure on peripheral nerves.

  • Assess patients for delirium risk factors (age older than 65 years, chronic cognitive decline, dementia, poor vision/hearing, critical illness, and infection).

  • Patients with postoperative delirium should receive multicomponent nonpharmacologic interventions, and pharmacologic interventions only if they pose substantial harm to themselves or others.

The John A. Hartford Foundation supported development of this guideline.

"Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline." ACS National Surgical Quality Improvement Program. Full text

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