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Pre-operative Assessment for Elderly Patient in ENT Presenter: Dr Isaac Tan Supervisor:Ms Aneeza Khairiyah Wan Hamizan Case 1 • An 81-year-old woman presented to the preoperative assessment clinic (PAC) prior to an elective endoscopic sinus surgery for chronic rhinosinusitis with bilateral grade 4 nasal polyposis. • She had a medical history of rheumatic heart disease, with a previous mitral valve replacement with a tissue valve, atrial fibrillation with chronic anticoagulation and pacemaker placement, and coronary artery disease. • She denied any cardiac symptoms except for mild shortness of breath on exertion. • The patient was taking metoprolol, valsartan, aspirin, simvastatin, and warfarin. • Her blood pressure was 150/81 mmHg, • heart rate was 78 beats/min, • oxygen saturation was 98% on room air. • Her heart beat was irregularly irregular without murmurs. Her lung sounds were clear. • There was no pitting edema. • Per the Revised Cardiac Risk Index (RCRI) for preoperative risk, the patient had one risk factor (coronary artery disease) with an expected risk of having a major postsurgical adverse cardiac event of 0.9%–1.1% Elderly Population in Malaysia • Despite the national census data classifying elders as those aged 65 and above, • Malaysia classifies elders as persons aged 60 years and above for its policy development related to older persons, following the United Nations World Assembly on Ageing held in Vienna in 1982. Source: 2018 National Health and Morbidity (NHMS) survey Pre-operative Assessment • to identify co-morbidities • To foresee and prevent patient complications during the anaesthetic, surgical, or post-operative period. • scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery. • RAP PRIOP - Reassurance, Advice, Prescription, Referral, Investigations, Observations, Patient understanding and follow-up: Preoperative Management For Geriatric Patients • increased age is associated with multiple systemic comorbidities. • Preoperative consent and postoperative delirium and cognitive dysfunction • Normal age-related physiologic changes such as • impaired left ventricular compliance, • stiffening of the systemic vasculature, • decreased lung mechanics, • reduced renal function • limit the physiologic reserve of older patients and make them more vulnerable to postoperative stress and illness. Domains for Elderly Adults Undergoing Elective Surgery Domain Description Goal Overall health goals Patient understanding of surgery and complication and outcome/QoL Function Baseline function – Eating, Dressing, Mobility, Social Support Nutrition Proper Nutritional Assessment Cognition Dementia risk/Consent Medical Illness Cardiac Pulmonary Endocrine Renal Medication management Marwell, J. G., Heflin, M. T., & McDonald, S. R. (2018). Preoperative Screening. Clinics in Geriatric Medicine, 34(1), 95–105. doi:10.1016/j.cger.2017.08.004 American Society of Anaesthesiologists Grade Grade Definition I II III IV V E Normal healthy patient Mild systemic disease Severe systemic disease Severe systemic illness that is a constant threat to life Moribund, who is not expected to survive without the operation Suffix added if an emergency operation Absolute Mortality (%) 0.1 0.2 1.8 7.8 9.4 – Modified Frailty Index (11) 1. 2. 3. 4. History of diabetes mellitus History of congestive heart failure History of hypertension requiring medication History of either transient ischemic attack or cerebrovascular accident 5. Functional status 2 (not independent) 6. History of myocardial infarction 7. History of either peripheral vascular disease or rest pain 8. History of cerebrovascular accident with neurological deficit 9. History of either COPD or pneumonia 10. History of either prior PCI, PCS, or angina 11. History of impaired sensorium Increasing mFI scores was associated with an increase in • wound infection, • wound occurrence, • any infection, • any occurrence of complications, • mortality. Farhat JS, Velanovich V, Falvo AJ, et al. Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg. 2012;72(6):1526– 1530. discussion 1530–1531. PreOperative History HOPI • Brief history of why the patient first attended • What procedure they have subsequently been scheduled for • Indication for surgery • NYHA/MMRC • Sepsis Symptoms • Airway Compromise and Compression Symptoms • Fall Risk – Otology surgery Pre-Operative History – Past Medical History Cardiovascular Disease • American Heart Association (ACC/AHA) perioperative guidelines, head and neck surgery is rated intermediate risk with a reported cardiac risk generally of 1%–5% . • History of Congenital anomalies/cardiac surgery • Recent IHD • Palpitation, Chest pain, Presyncope attacks NYHA Classification Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Class III - Marked limitation in activity due to symptoms, even during less-thanordinary activity, e.g. walking short distances (20 100 m).Comfortable only at rest. Class IV - Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients. Cardiovascular Risk Assessment – Revised Cardiac Risk Index for Pre-Operative Risk (RCRI – 2019) for non cardiac surgery Risk factor High-risk surgery History of ischemic heart disease History of congestive heart failure History of cerebrovascular disease Pre-operative treatment with insulin Description Intraperitoneal; intrathoracic; suprainguinal vascular History of myocardial infarction (MI); history of positive exercise test; current chest pain considered due to myocardial ischemia; use of nitrate therapy or ECG with pathological Q waves Pulmonary edema, bilateral rales or S3 gallop; paroxysmal nocturnal dyspnea; chest x-ray (CXR) showing pulmonary vascular redistribution Points +1 Prior transient ischemic attack (TIA) or stroke +1 -- +1 +1 +1 Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O'Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50. Revised Cardiac Risk Index for Pre-Operative Risk (RCRI – 2019) for non cardiac surgery RCRI Score Risk of major cardiac event (95% CI)* Management 0 3.9% (2.8-5.4%) No Preop cardiac assessment needed 1 6.0% (4.9-7.4%) the patient’s age is ≥65, or they are ≥40, with significant cardiac disease* 2 10.1% (8.1-12.6%) ≥3 15% (11.1-20.0%) monitored with an ECG in the PACU and troponin measurements daily for 48-72 hours Defined as death, myocardial infarction, or cardiac arrest at 30 days after noncardiac surgery PERIOPERATIVE APPROACHES FOR HYPERTENSION PATIENT • Exaggerated intraoperative blood pressure fluctuation is associated ECG evidence of myocardial ischaemia and stroke • Haemostasis intraoperatively • Renal Function Myocardium Infarction / PCI • < 12 months • Elective – Postpone surgery until 12 post stenting • Urgent – Consider Bridging therapy • >12 months • High risk - Consider Bridging therapy • Low Risk – Consider single ASA Pacemaker / Cardioverter Defibrillator • Implantable Pacemakers and implantable ICDs in patients face problems resulting from Electrical interference from the use of surgical diathermy / electro-cautery • If Cautery is deemed essential – BIPOLAR with limit to short bursts • History • INDICATION for DEVICE • device manufacturer, model number, serial number • implanting hospital, follow-up hospital • date of implant • extent of any heart failure • degree of pacemaker dependency • Facial Nerve Stimulation - could be considered with caution in patients with pacemakers and ICDs with lowest amplitude possible. Ground electrode should be place away from thorax (*Limited studies for facial nerve, more on lower limb stimulation) Badger J, Taylor P, Swain I. The safety of electrical stimulation in patients with pacemakers and implantable cardioverter defibrillators: A systematic review. J Rehabil Assist Technol Eng. 2017;4:2055668317745498. Published 2017 Dec 5. doi:10.1177/2055668317745498 PERIOPERATIVE MANAGEMENT OF PATIENTS ON ANTI-THROMBOTIC THERAPY • Aspirin • In patients at moderate to high risk - continuing ASA around the time of surgery • In patients at low risk for cardiovascular events - stopping ASA 7 to 10 days before surgery • Dual Anti-platelet - continuing ASA around the time of surgery and stopping • clopidogrel/prasugrel 5 days before • Ticlopidine 10 -14 days before • Vitamin K Antagonist / Warfarin – • Low risk – 5 days before • High risk In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thrombo-embolism, bridging anticoagulation (UFH,LMWH) 1 -2 days before surgery • IV Unfractionated Heparin - stopping 4 to 6 h before surgery • LMWH (Clexane) – stopping 24 hours before surgery, if high risk bleeding – 48 – 72 hours before PERIOPERATIVE MANAGEMENT OF PATIENTS ON NEW ANTI-THROMBOTIC THERAPY • Dabigatran – Stop 1 to 2 days (CrCl ≥ 50 mL/min) or 3 to 5 days (CrCl < 50 mL/min). Consider longer times for patients undergoing major surgery • Rivaroxaban - Stop rivaroxaban at least 24 hours before procedure. If reduced Renal function, consider longer times and bridge with UWFH if the risk of thrombo-embolism is high • Apixaban - Discontinue at least 48 hours before elective surgery and bridge with UWFH if the risk of thrombo-embolism is high • Edoxaban – Discontinue 2–3 days prior and bridge with UWFH if the risk of thrombo-embolism is high Anti-thrombotic Therapy And Its Antidotes Drug Antidote Antiplatelets – ASA, Clopidogrel None – Consider Platelet infusion Warfarin Vitamin K UFW Heparin protamine sulfate – dosage depending of time since last heparin dose LMW Heparin (Clexane) None - Limited role of protamine sulfate Dabigatran Idarucizumab Rivaroxaban Andexanet alfa Apixaban Charcoal (if last intake within 2–3 hours) IV Prothrombin complex concentrate Edoxaban Charcoal (if last intake within 2–3 hours) IV Prothrombin complex concentrate Case 1 • Perioperatively, she was also bridged with low molecular weight heparin and unfractionated heparin. • Her postoperative course was uneventful, and she was discharged on postoperative day (POD) 2 to home. Respiratory disease • adequate oxygenation and ventilation is essential in reducing the risk of acute ischaemic events in the peri-operative period • Important to assess risk of postoperative pulmonary complications • MMRC • Asthma / COPD – pre op nebulisation (On and OT call) • Smoking cessation – 4 – 8 weeks prior to surgery • Respiratory muscle training (incentive spirometry) to maximize respiratory support in preparation for upcoming surgery that may be particularly beneficial for high-risk surgeries, as it reduces the risk of postoperative atelectasis and pneumonia mMRC (Modified Medical Research Council) Dyspnea Scale Grade Symptom severity 0 Dyspnea only with strenuous exercise 1 Dyspnea when hurrying or walking up a slight hill 2 Walks slower than people of the same age because of dyspnea or has to stop for breath when walking at own pace 3 Stops for breath after walking 100 yards (91 m) or after a few minutes 4 Too dyspneic to leave house or breathless when dressing Renal disease • many features of renal disease (such as anaemia, coagulopathy, biochemical disturbances) can increase the incidence of surgical complications • Fluid restriction • Type of renal replacement therapy • Dry weight • Urine output at home • Dialysis Frequency, Centre, Complications Endocrine disease • specifically diabetes mellitus and thyroid disease • Many medications often require specific changes to be made in the peri-operative period Preoperative Assessment For Patients With Diabetes Mellitus • Should focus on the long-term complications of diabetes (microvascular, macrovascular, and neuropathic), which may potentiate risk. • Pharmacological regimen - Medication type, Dosage. Timing • Control – HbA1c • End Organ Damage – Renal Function, Cardiac Function Principles Of Management for Patients With Diabetes Mellitus 1. Stabilise bood sugar 2-3 days before elective operation. 2. OHA - Omit Morning dose of OHA 3. Insulin - Omit morning dose of insulin if BG <7mmol/L or Half the normal dose if >7 mmol/L 4. Major surgery - Convert to insulin (sliding scale) for major surgery or one with poor control on oral hypoglycaemic drugs. 5. Short acting drugs are preferred to long acting ones. 6. If possible the patient should be scheduled early in the OT list to limit the durationof preoperative fasting 7. Bedside blood glucose concentration monitoring using reagent strip and refractometer is usually adequate Sliding Scale Regime • Variable rate infusion of insulin 50U in 50mls 0.9% saline (concentration of insulin 1U/ml), adjusted according to blood glucose concentration. • Increase rate of infusion by 2mls/hr if blood glucose concentration remains high, check halfhourly and adjust infusion rate accordingly. • Approximate guide : Insulin infusion rate= Blood glucose concentration divide by 5 Blood Glucose Concentration Infusion rate (ml/hr) <5 Omit 5 – 10 1 10 – 15 3 15 – 20 4 >20* 5* PREOPERATIVE ASSESSMENT OF PATIENTS WITH THYROID DISORDER • For all symptomatic patients, REFER Endocrine Medical Clinic for early appointment • If clinically asymptomatic , but only have laboratory thyroid abnormalities • If biochemically hyper or hypothyroid : REFER • If subclinical hypothyroidism or subclinical hyperthyroidism to send for Free T3 Level. If normal free T3, can proceed for surgery. • If TSH ↑ : Repeat TFT in 4 weeks time Preoperative Assessment For Patients With Obesity/OSA • Sedative premedication: Avoid sedative premedication • Possible difficult airway • Positive Airway Pressure Devices should be continued till the night before op and resumed as soon as possible after operation. Patient to bring own device to hospital • Gastro-oesophageal reflux disease - Proton pump inhibitors or antacids for premedication • PACU/ICU back up depends on ASA Perioperative risk estimation in patients with obstructive sleep apnea Nutritional History • Identify Pre-operative malnutrition • Provide nutritional support improves surgical outcome Nasogastric tube Gastrostomy Jejunostomy • If unable to take sufficient calories orally or dysfunctional swallow • If oesophagus blocked/dysfunctional • If stomach inaccessible or outflow obstruction Parenteral Nutrition (TPN) • If jejunum inaccessible or intestinal failure (IF) Nutritional status • prevalence of malnutrition among the elderly was 22.8% • Morbidity, particularly severe infection, was significantly higher among malnourished patients, with the odds ratio for morbidity ranging from 2.30 to 3.47 in the well-nourished vs malnourished patients • Traditional scoring systems are based on mathematical equations using objective measures of nutritional status (eg, Nutritional Risk Index [NRI] • Subjective global assessment (SGA) of nutritional status tool Subjective Global Assessment Objective Assessment • NRI = [1.489× serum albumin, (g/L)] + [41.7× present weight/usual weight] • >100: not malnourished • 97.5–100: mild malnourishment • 83.5–97.5: moderate malnourishment • <83.5: severe malnourishment • Maastricht Index =20.68 − [0.24× albumin (g/L)] − [19.21× prealbumin (g/L)] − [1.86× lymphocytes, (106/L)] − [0.04× ideal body weight] Psychological evaluation and preparation • Dementia is a known risk factor for morbidity and mortality in the geriatric population • Adult patients undergoing laryngectomy may experience very intrusive, lifechanging impact from loss of speech. • A preoperative preparation program and counselling have been shown to alleviate anxiety in not only elderly patients, but also family members • mild dementia does not preclude capacity for medical decision-making. • In general, decision-making capacity requires three basic elements: 1. the capacity to understand and communicate; 2. the capacity to reason and deliberate; 3. possession of a set of values and goals Pre-Operative History – Past Surgical and Anaesthetic History Past Drug History • One in 3 older adults takes 5 or more prescription medications and, as a result, has a high risk of adverse drug events in the perioperative period Physical Assessment • Vital Signs • Cardiovascular/Pulmonary • Mobility assessment - Neck • Airway assessment • Otology • Rhinology • Laryngology Pre-Operative Investigations Routine Investigation Indication Full blood count Age 60 and above Major surgery Renal profile Major surgery Electrocardiogram (ECG) Male – Age 40 and above Female – Age 50 and above Chest X-ray Age 60 and above Major surgery Liver Function Major Surgery in patients more than 50 and above Blood Sugar Monitoring Age above 60 • Major surgery is empirically defined as one in which the cranium, thorax or abdomen is opened or when the anticipated blood loss is significant and exceeds 15% of total blood volume. • Normal investigation results are valid for varying periods of time, ranging • from 1 week (FBC, urea, renal profile, blood glucose concentration), • 1 month (ECG) to 6 months (CXR). College of Anaesthesiologist Academy of Medicine of Malaysia Recommendations on Pre-Anaesthetic Assessment and Management 2014 Pre-Operative Investigations Routine Investigation Indication – Comorbids Full blood count 1. Anaemia and Other haematological disease 2. Renal disease 3. Patient on chemotherapy Renal profile 1. 2. 3. 4. 5. 6. 7. Electrocardiogram (ECG) 1. Heart disease, hypertension or chronic pulmonary disease 2. Diabetes mellitus 3. Renal disease Chest X-ray 1. Significant respiratory disease 2. Cardiovascular disease 3. Malignancy Blood sugar Diabetes mellitus Liver Disease Renal disease Liver diseases Cardiovascular disease Metabolic disease, e.g., diabetes mellitus and Abnormal nutritional states History of diarrhoea, vomiting Preoperative bowel preparation Drugs that may alter electrolyte balance or nephrotoxic e.g., diuretics, corticosteroids Group Save and Hold (GSH) VS Group Cross-Match (GXM) Group Save and Hold (GSH) • Determines patient’s blood group (ABO and RhD) • screens the blood for any atypical antibodies; Group Cross-Match (GXM) physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places Takes around 40 minutes Valid for 48 hours no blood is issued recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected 40 mins for GSH + 40 mins GXM Valid for 24 hours donor blood is issued and reserved should be done if blood loss is anticipated RhD negative patients, blood bank must be informed at least a week prior to the procedure so as to ensure blood is available before surgery MAXIMUM SURGICAL BLOOD ORDERING SCHEDULE (MSBOS) Surgery Recommendation Otology Mastoidectomy-radical 2 units Rhinology Skull Base Tumors 4 Units Laryngology Larnyngectomy -total/partial +/- pharyngectomy 2 – 4 units Head and Neck Adenoidectomy/Adenotonsillectomy/Tonsillectomy GSH* Angiofibroma excision 4 – 6 units Free Flap Reconstructions 2 – 4 units Parotidectomy-complete/partial 2 units* Radical neck dissection 2 units* Glossectomy with / without neck dissection 2 – 4 units College of Anaesthesiologist Academy of Medicine of Malaysia Recommendations on Pre-Anaesthetic Assessment and Management 2014 Pre-Operative Investigations Routine Investigation Indication – Comorbids Liver Function 1. Hepatobiliary disease 2. History of alcohol abuse 3. Tumour with possible metastases to the liver Arterial blood gases (ABG) 1. 2. 3. 4. Debilitated or septic patients Moderate to severe pulmonary disease Patients in respiratory difficulty Patients scheduled for thoracic surgery Coagulation screen 1. 2. 3. 4. 5. Haematological disease Severe liver disease Coagulopathy due to any cause Patients on anticoagulant therapy Intra-thoracic/Intra-cranial procedures Thyroid function test 1. Thyroid surgery 2. History of thyroid disease 3. Suspected endocrine abnormalities, e.g., pituitary tumour Lung function test 1. Patients scheduled for thoracic surgery 2. Moderate to severe pulmonary disease Cardiac Function Test – ECHO/Stress Test/Holter 1. Significant cardiovascular disease 2. Patients with atypical cardiac symptoms – palpitations, presyncopal 3. Patients with significant haemodynamic disturbances Covid Era – New Normal • In our inpatient pathway, all patients were tested prior to procedures. • Although patients undergoing emergent and urgent cases received the same day test, procedures were not delayed for test results, and they proceeded with appropriate PPE and precautions • Types of testing • Low risk/weekends - Rapid Antigen test • High risk - rtPCR Thank You References • Abdelmalak, B., & Doyle, J. (Eds.). (2012). Anesthesia for Otolaryngologic Surgery. doi:10.1017/cbo9781139088312 • Kim S, Brooks AK, Groban L. Preoperative assessment of the older surgical patient: honing in on geriatric syndromes. Clin Interv Aging. 2014;10:13-27. Published 2014 Dec 16. doi:10.2147/CIA.S75285 • Kumar C, Salzman B, Colburn JL. Preoperative Assessment in Older Adults: A Comprehensive Approach. Am Fam Physician. 2018;98(4):214-220.